Basic Information
| Provider Information | |||||||||
| NPI: | 1073716775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GWATHMEY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91734 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232911734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043586100 | ||||||||
| FaxNumber: | 8043427619 | ||||||||
| Practice Location | |||||||||
| Address1: | 11958 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | HENRICO | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232331007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048289350 | ||||||||
| FaxNumber: | 8048271744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 0101250349 | VA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.