Basic Information
| Provider Information | |||||||||
| NPI: | 1457719106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEHOUX | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575944006 | ||||||||
| FaxNumber: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 J CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE 603 | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575345340 | ||||||||
| FaxNumber: | 7575943456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2016 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | 0024173246 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 363L00000X | 0024173246 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1457719106 | 05 | VA | MEDICAID |