Provider Demographics
NPI:1942801428
Name:STIMPSON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STIMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 TAPPAHANNOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-9320
Mailing Address - Country:US
Mailing Address - Phone:804-443-1988
Mailing Address - Fax:
Practice Address - Street 1:1660 TAPPAHANNOCK BLVD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-9320
Practice Address - Country:US
Practice Address - Phone:804-443-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist