Provider Demographics
NPI:1275040511
Name:DEVORE, KATERINA LYNN
Entity Type:Individual
Prefix:
First Name:KATERINA
Middle Name:LYNN
Last Name:DEVORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DARDANELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72834-3802
Mailing Address - Country:US
Mailing Address - Phone:479-229-6191
Mailing Address - Fax:479-229-6194
Practice Address - Street 1:200 N 3RD ST
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-3802
Practice Address - Country:US
Practice Address - Phone:479-229-6191
Practice Address - Fax:479-229-6194
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily