1164492138 NPI number — KELLY GAIL BARRIAULT PA

Table of content: KELLY GAIL BARRIAULT PA (NPI 1164492138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164492138 NPI number — KELLY GAIL BARRIAULT PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARRIAULT
Provider First Name:
KELLY
Provider Middle Name:
GAIL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MELTON
Provider Other First Name:
KELLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1164492138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1035 CHAMPIONS WAY
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SUFFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23435-3762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-394-1540
Provider Business Mailing Address Fax Number:
757-967-0793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 WIMBLEDON SQ
Provider Second Line Business Practice Location Address:
STE. E
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-4945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-547-9830
Provider Business Practice Location Address Fax Number:
757-548-0721
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  0110002088 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1164492138 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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