Basic Information
Provider Information | |||||||||
NPI: | 1316433154 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FILLERS | ||||||||
FirstName: | KAITLYN | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CSFA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15 MEDICAL DR NE STE 201 | ||||||||
Address2: |   | ||||||||
City: | CARTERSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 301218005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7703865221 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 15 MEDICAL DR NE STE 201 | ||||||||
Address2: |   | ||||||||
City: | CARTERSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 301218005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7703865221 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2018 | ||||||||
LastUpdateDate: | 07/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 157270 | GA | Y |   | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
ID Information
ID | Type | State | Issuer | Description | 157270 | 01 | GA | THE NATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING | OTHER |