Provider Demographics
NPI:1548505563
Name:EREZO, KATHLEEN BUSTAMANTE VIADO (FNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BUSTAMANTE VIADO
Last Name:EREZO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:BUSTAMANTE
Other - Last Name:VIADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1925 GLENN MITCHELL DR STE 202
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0177
Mailing Address - Country:US
Mailing Address - Phone:757-507-0900
Mailing Address - Fax:757-301-6462
Practice Address - Street 1:1925 GLENN MITCHELL DR STE 202
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-0177
Practice Address - Country:US
Practice Address - Phone:757-507-0900
Practice Address - Fax:757-301-6462
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170340363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01813205Medicare PIN
VAVV8741AMedicare PIN
VA-033OtherTRICARE/CHAMPUS
VA1548505563Medicaid
VA10103722NOtherOPTIMA HEALTH
VA1548505563OtherVIRGINIA PREMIER HEALTH PLAN
VAPAROtherUSA MANAGED CARE
NC7006523Medicaid
VAPAROtherMULTIPLAN