Provider Demographics
NPI:1346776507
Name:PATRICK, KENNERLY CLINTON (DO)
Entity type:Individual
Prefix:
First Name:KENNERLY
Middle Name:CLINTON
Last Name:PATRICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 EAST MARSHALL ST. PO BOX 980160
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298
Mailing Address - Country:US
Mailing Address - Phone:804-828-9682
Mailing Address - Fax:804-828-7567
Practice Address - Street 1:1101 EAST MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298
Practice Address - Country:US
Practice Address - Phone:804-828-9682
Practice Address - Fax:804-828-7567
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102207203207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine