Provider Demographics
NPI:1366005605
Name:PROSSER, KATIE M (DO)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:PROSSER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-794-2457
Mailing Address - Fax:423-283-9480
Practice Address - Street 1:1242 W SHIPLEY FERRY RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-3323
Practice Address - Country:US
Practice Address - Phone:423-239-7300
Practice Address - Fax:423-239-7607
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN4833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program