Basic Information
| Provider Information | |||||||||
| NPI: | 1093796146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUSTUS | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2377 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242662377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768893700 | ||||||||
| FaxNumber: | 2768895505 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 EAST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242661100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768893700 | ||||||||
| FaxNumber: | 2768895505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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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 | 363LF0000X | 0024166373 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 0024166373 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1093796146 | 05 | VA | MEDICAID | 010261295 | 05 | VA | MEDICAID |