Basic Information
| Provider Information | |||||||||
| NPI: | 1548260912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRATT | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | KELLAM | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLAM | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 CONCOURSE BLVD | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230595643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045494030 | ||||||||
| FaxNumber: | 8045494032 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 CHARLES DIMMOCK PKWY | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238342940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045267364 | ||||||||
| FaxNumber: | 8045267394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 07/31/2014 | ||||||||
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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 | 207N00000X | 0101231692 | VA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | P00047267 | 01 | RAILROAD MEDICARE | OTHER | 7442479 | 01 | AETNA | OTHER | 010008280 | 05 | VA | MEDICAID | 0300585 | 01 | UNITED HEALTHCARE | OTHER | 230056 | 01 | SOUTHERN HEALTH | OTHER | 465745 | 01 | ANTHEM | OTHER |