Provider Demographics
NPI:1831254093
Name:MOFFITT, KATHLEEN T (CERTIFIED NURSE MIDW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:T
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:CERTIFIED NURSE MIDW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 24TH ST
Mailing Address - Street 2:KENNER CLINIC AT FORT LEE
Mailing Address - City:FORT LEE
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-9942
Mailing Address - Fax:877-874-1008
Practice Address - Street 1:11730 SUDLEY MANOR DRIVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2843
Practice Address - Country:US
Practice Address - Phone:703-257-3001
Practice Address - Fax:703-257-3133
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024073304363L00000X
VA0001073304363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q17345Medicare UPIN
004629K32Medicare ID - Type Unspecified