Provider Demographics
NPI:1730263807
Name:DIEFENDERFER, KATHERINE GRUBBS (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GRUBBS
Last Name:DIEFENDERFER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:K
Other - Last Name:GRUBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7001 FOREST AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1726
Mailing Address - Country:US
Mailing Address - Phone:804-288-0808
Mailing Address - Fax:804-288-8887
Practice Address - Street 1:7001 FOREST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1726
Practice Address - Country:US
Practice Address - Phone:804-288-0808
Practice Address - Fax:804-288-8887
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166667363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010207100Medicaid
VAC09462OtherGROUP PTAN
VA008817M84Medicare ID - Type UnspecifiedC03684
VAQ55266Medicare UPIN