Provider Demographics
NPI:1831427541
Name:HAIRSTON, TRIVINIA KELLAM (RN)
Entity type:Individual
Prefix:
First Name:TRIVINIA
Middle Name:KELLAM
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 BEAVER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-3073
Mailing Address - Country:US
Mailing Address - Phone:276-547-1585
Mailing Address - Fax:276-647-1585
Practice Address - Street 1:375 BEAVER RIDGE RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078-3073
Practice Address - Country:US
Practice Address - Phone:276-547-1585
Practice Address - Fax:276-647-1585
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001134098253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care