Basic Information
| Provider Information | |||||||||
| NPI: | 1881060697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWKINS | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | MAYO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MAYO | ||||||||
| OtherFirstName: | KAITLIN | ||||||||
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| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 911 N 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307052115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066954676 | ||||||||
| FaxNumber: | 7066957364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2015 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT002974 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.