Provider Demographics
NPI:1407061971
Name:JOHN, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:JOHN
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 1:943 HAULAPAI WAY
Mailing Address - Street 2:
Mailing Address - City:PEACH SPRINGS
Mailing Address - State:AZ
Mailing Address - Zip Code:86434
Mailing Address - Country:US
Mailing Address - Phone:928-769-2922
Mailing Address - Fax:928-769-2933
Practice Address - Street 1:943 HAULAPAI WAY
Practice Address - Street 2:
Practice Address - City:PEACH SPRINGS
Practice Address - State:AZ
Practice Address - Zip Code:86434
Practice Address - Country:US
Practice Address - Phone:928-769-2922
Practice Address - Fax:928-769-2933
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1598795825Medicare ID - Type Unspecified