Provider Demographics
NPI:1245270818
Name:WADE, KATHLEEN A (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:WADE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 746871
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6871
Mailing Address - Country:US
Mailing Address - Phone:469-727-6675
Mailing Address - Fax:
Practice Address - Street 1:5246 CHAMBERLAYNE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-2950
Practice Address - Country:US
Practice Address - Phone:804-913-7029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024468818363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2585546Medicaid
OH2585546Medicaid
OH2585546Medicaid
OHMYNP17023Medicare PIN