KELLY ELIZABETH WALLACE NP
NPI 1417609694
Nurse Practitioner in Petersburg, VA
About Kelly Elizabeth Wallace Np NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
KELLY ELIZABETH WALLACE NP (NPI 1417609694) is an individual nurse practitioner in Petersburg, Virginia, licensed in Virginia (0024183547) and active in the NPI registry since January 2022. She is enrolled in Medicare PECOS, is affiliated with Bon Secours St Marys Hospital, and is a graduate of Other (2021).
NPPES Registry Identity
Specialties & Licenses
Medicare Participation & PECOS CMS
Medicare enrollment, assignment, billing reassignment, and ordering and referring status from CMS.
Medicare Enrollment Status
Enrolled in Medicare and accepts Medicare assignment
Kelly Elizabeth Wallace Np is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.
Medicare Billing Reassignments
3Medicare enrollment records show Kelly Wallace reassigns Medicare billing to 3 organizations. Each organization bills Medicare for the services this provider delivers there; the nearest is listed first.
Richmond, VA 23226
- Reassigned Medicare billing, Virginia enrollment
- 99 clinicians in this Medicare group
Franklin, VA 23851
- Reassigned Medicare billing, Virginia enrollment
- 219 clinicians in this Medicare group
Culpeper, VA 22701
- Reassigned Medicare billing, Virginia enrollment
- 1,294 clinicians in this Medicare group
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Areas of Expertise CMS Part B claims 2
Services this provider delivered to Medicare fee-for-service patients, from the CMS Medicare utilization data. Higher counts generally reflect more experience with a service; care delivered outside Medicare is not included.
Hospital Affiliations CMS Care Compare 2
Hospitals where this provider delivers care, identified from recent Medicare claims and place-of-service records.
Bon Secours St Marys Hospital
Acute Care Hospitals · Richmond, VABon Secours St Francis Medical Center
Acute Care Hospitals · Midlothian, VAPhysician Visit Costs CMS claims · ZIP area
Typical Medicare office-visit costs in the 23805 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.
Other Providers at the Same Location NPPES 20
Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.
PETERSBURG, VA 23805
PETESBURG, VA 23805
PETERSBURG, VA 23805
PETERSBURG, VA 23805
Frequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is Kelly Wallace's NPI number?
The NPI number for Kelly Wallace is 1417609694. It was assigned to this individual provider in the NPPES registry on January 19, 2022.
Where is Kelly Wallace located?
Kelly Wallace practices at 200 Medical Park Blvd, Petersburg, VA 23805. The listed phone number is (804) 765-5000.
What is Kelly Wallace's specialty?
The primary specialty registered for this NPI is Nurse Practitioner with taxonomy code 363L00000X.
Is Kelly Wallace enrolled in Medicare?
Yes. Kelly Wallace is registered in the Medicare PECOS system and accepts Medicare assignment, which means accepting the Medicare-approved amount as payment in full for covered services.
Which organizations bill Medicare for Kelly Wallace's services?
According to the CMS Revalidation Reassignment List (October 2026 release), Kelly Wallace reassigns Medicare benefits to 3 organizations: Cep America, LLC (Richmond, VA), Alexandria Springfield Emergency Physicians PC (Franklin, VA) and Emergency Medicine Associates P.A., P.C. (Culpeper, VA). Each reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for Kelly Wallace's services. Reassignment records can lag staffing changes; confirm current arrangements with the organization.
Is Kelly Wallace affiliated with any hospitals?
According to CMS data, Kelly Wallace is affiliated with Bon Secours St Marys Hospital and Bon Secours St Francis Medical Center.
When was this NPI record last updated?
The NPPES record for Kelly Wallace was last updated on January 27, 2022. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 4 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# Kelly Elizabeth Wallace, NP · NPI 1417609694
Nurse Practitioner physician in Petersburg, Virginia. Individual provider, active in the CMS NPPES registry since January 19, 2022.
## Identity
- **NPI:** 1417609694 (Entity type: Individual)
- **Enumerated:** January 19, 2022
- **Primary specialty:** Nurse Practitioner · taxonomy 363L00000X
- **State license:** 0024183547 (Virginia)
- **Sole proprietor:** Yes
## Practice location
- **Address:** 200 MEDICAL PARK BLVD, Petersburg, VA 23805-9274
- **Phone:** (804) 765-5000
## Medicare
- **Medicare:** Enrolled (PECOS); accepts Medicare assignment
- **Ordering & referring:** eligible for Part B labs & imaging, durable medical equipment, home health, power mobility devices
- **Bills Medicare through:** 3 organizations under Medicare reassignment (form CMS-855R): Cep America, LLC (NPI 1629722129, Richmond, VA); Alexandria Springfield Emergency Physicians PC (NPI 1740529700, Franklin, VA); Emergency Medicine Associates P.A., P.C. (NPI 1881559102, Culpeper, VA) · CMS Revalidation Reassignment List, October 2026 release
- **Medical school:** Other, class of 2021
## Record status
- **NPPES last updated:** January 27, 2022
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Source: [NPI Profile](https://npiprofile.com/npi/1417609694) · Data from the CMS NPPES public registry.