NPIMap

Individual provider Active NPI

Kelly Elizabeth Wallace, NP

  • Nurse Practitioner
  • Petersburg, VA
National Provider Identifier
1417609694
Registry record updated Jan 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
License
0024183547 Issued in VA
Practice address
200 Medical Park Blvd
Petersburg, VA 23805-9274
Phone
(804) 765-5000
NPI assigned
Jan 19, 2022
Last updated
Jan 27, 2022By the provider in NPPES
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Jan 27, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse Practitioner 363L00000X 0024183547 VA Primary

Addresses

Primary practice location

200 Medical Park Blvd
Petersburg, VA 23805-9274

Mailing address

2610 Setting Sun Dr
Powhatan, VA 23139-7552
Phone (910) 443-1679

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20220202001007 VA Practitioner - Nurse Practitioner 9537552286 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2021
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Cep America LLCGroup PAC ID 6608056171, 995 clinicians

Practice addresses (Care Compare)

5801 Bremo Rd
Richmond, VA 23226-1907
Phone (804) 285-2011

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
95.52 of 100Reported as group
Quality
91.6
Improvement activities
40

Merit-based Incentive Payment System (MIPS)

Final score
87.3 of 100Reported as group
Quality
70.94
Improvement activities
40
Cost
92.94

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Emergency Medicine Associates, P.a.,P.C. CurrentSince Oct 29, 2021 Accepting new patients
Cep America, LLC Emergency Medicine CurrentSince Feb 1, 2024 Accepting new patients
Cep America LLC Emergency Medicine CurrentSince Feb 1, 2024 Accepting new patients
Alexandria Springfield Emergency Physicians PC Emergency Medicine CurrentSince Jan 30, 2022 Accepting new patients
Alexandria Springfield Emergency Physicians PC Emergency Medicine CurrentSince Jan 30, 2022 Accepting new patients
Emergency Medicine Associates P.a., P.C. CurrentSince Oct 29, 2021 Accepting new patients
Arnot Medical Services PLLC Emergency Medicine Past Accepting new patients

Locations

1601 Cummins Dr
Ste D
Modesto, CA 95358
Phone (510) 350-2663

12420 Milestone Center Dr
Ste 200
Germantown, MD 20876
Phone (336) 509-7515

60 E Roslyn Ct
Colonial Hgts, VA 23834
Phone (804) 281-8100

100 Fairview Dr
Franklin, VA 23851
Phone (757) 516-1153

15225 Heathcote Blvd
Haymarket, VA 20169
Phone (571) 284-1000

8700 Sudley Rd
Manassas, VA 20110
Phone (703) 369-8000

8260 Atlee Rd
Mechanicsvlle, VA 23116
Phone (804) 264-6000

601 Watkins Centre Pkwy
Midlothian, VA 23114
Phone (804) 594-2100

200 Medical Park Blvd
Petersburg, VA 23805
Phone (804) 765-5000

5801 Bremo Rd
Richmond, VA 23226
Phone (804) 281-8220

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 17

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1642550400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1643241600000",
    "number": "1417609694",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2610 SETTING SUN DR",
            "city": "POWHATAN",
            "state": "VA",
            "postal_code": "231397552",
            "telephone_number": "910-443-1679"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 MEDICAL PARK BLVD",
            "city": "PETERSBURG",
            "state": "VA",
            "postal_code": "238059274",
            "telephone_number": "804-765-5000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KELLY",
        "middle_name": "ELIZABETH",
        "credential": "NP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-01-19",
        "last_updated": "2022-01-27",
        "certification_date": "2022-01-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "VA",
            "license": "0024183547",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Petersburg, VA

Sources for this page

Verify at the official NPI Registry.