Provider Demographics
NPI:1407893217
Name:COVINGTON, KATIE BODYCOMB (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:BODYCOMB
Last Name:COVINGTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 STONEFOREST DR STE 320
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4881
Mailing Address - Country:US
Mailing Address - Phone:770-516-5199
Mailing Address - Fax:678-213-1851
Practice Address - Street 1:100 STONEFOREST DR STE 320
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-4881
Practice Address - Country:US
Practice Address - Phone:770-516-5199
Practice Address - Fax:678-213-1851
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003796363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
97WCHMWMedicare ID - Type Unspecified
P57969Medicare UPIN