Basic Information
| Provider Information | |||||||||
| NPI: | 1811452576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW KENT PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 7410 COOPER TAVERN RD STE B | ||||||||
| Address2: | |||||||||
| City: | QUINTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231412257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042233608 | ||||||||
| FaxNumber: | 8042233648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2019 | ||||||||
| LastUpdateDate: | 07/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRADY | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7577845808 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.