Basic Information
| Provider Information | |||||||||
| NPI: | 1922624865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOHLENBERG | ||||||||
| OtherFirstName: | KATIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1940 STONEGATE DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA HLS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352422541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059779876 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4810 WHITESPORT CIR SW STE 110 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358017439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059779876 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA.1575 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.