Provider Demographics
NPI:1861985806
Name:PANKEY, KENNETH (BA QMHP-A)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PANKEY
Suffix:
Gender:M
Credentials:BA QMHP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6324 MANASSAS DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-7884
Mailing Address - Country:US
Mailing Address - Phone:804-219-9554
Mailing Address - Fax:
Practice Address - Street 1:2819 N PARHAM RD STE 260
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-4425
Practice Address - Country:US
Practice Address - Phone:804-219-9554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3485101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3485Medicaid