Basic Information
| Provider Information | |||||||||
| NPI: | 1548505563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EREZO | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VIADO | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | B. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | EVMS MEDICAL GROUP | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465908 | ||||||||
| FaxNumber: | 7574467055 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 W BRAMBLETON AVE | ||||||||
| Address2: | EVMS MEDICAL GROUP | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235101005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465908 | ||||||||
| FaxNumber: | 7574467055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2012 | ||||||||
| LastUpdateDate: | 04/26/2017 | ||||||||
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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 | 0024170340 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.