Provider Demographics
NPI:1326656091
Name:HERMANN, KATHERINE NICOLE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NICOLE
Last Name:HERMANN
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 1:4520 E BASELINE RD APT 2025
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-7432
Mailing Address - Country:US
Mailing Address - Phone:314-952-8699
Mailing Address - Fax:
Practice Address - Street 1:8950 W ILLINI RD
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-4600
Practice Address - Country:US
Practice Address - Phone:623-478-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP12551390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program