Provider Demographics
NPI:1316354863
Name:NEELEY, KENDRA ALISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:ALISE
Last Name:NEELEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KENDRA
Other - Middle Name:ALISE
Other - Last Name:SAMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:
Practice Address - Street 1:12655 WARWICK BLVD STE A
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2501
Practice Address - Country:US
Practice Address - Phone:757-223-4118
Practice Address - Fax:757-595-0362
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005955363A00000X
KYPA1941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant