Provider Demographics
NPI:1912514209
Name:STAPLETON, KALA RUTHERFORD
Entity type:Individual
Prefix:
First Name:KALA
Middle Name:RUTHERFORD
Last Name:STAPLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 COLUMBO DR
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24263-7870
Mailing Address - Country:US
Mailing Address - Phone:276-870-0122
Mailing Address - Fax:
Practice Address - Street 1:1800 COMBS RD STE 12
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-1808
Practice Address - Country:US
Practice Address - Phone:276-546-4894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180271363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care