Basic Information
| Provider Information | |||||||||
| NPI: | 1639758311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERVIN | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | Z | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 N SHALLOWFORD RD STE B | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303386476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047786920 | ||||||||
| FaxNumber: | 4047786811 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 N SHALLOWFORD RD STE B | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303386476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047278868 | ||||||||
| FaxNumber: | 4047271174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2021 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.