Provider Demographics
NPI:1629199815
Name:OSBORNE, KELLY SCHROCK (CPNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SCHROCK
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 SALEM CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6484
Mailing Address - Country:US
Mailing Address - Phone:540-899-3440
Mailing Address - Fax:540-899-3434
Practice Address - Street 1:2632 SALEM CHURCH RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6484
Practice Address - Country:US
Practice Address - Phone:540-899-3440
Practice Address - Fax:540-899-3434
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164863363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010123666Medicaid
VAP81431Medicare UPIN