Provider Demographics
NPI:1043920606
Name:PEMBROKE, KRISTA (NP)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:PEMBROKE
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1083 INDEPENDENCE BLVD STE 803
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5523
Mailing Address - Country:US
Mailing Address - Phone:757-317-0042
Mailing Address - Fax:
Practice Address - Street 1:1083 INDEPENDENCE BLVD STE 803
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5523
Practice Address - Country:US
Practice Address - Phone:757-317-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185772363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health