Provider Demographics
NPI:1487224044
Name:BERKLEY, KATIE ELISA (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ELISA
Last Name:BERKLEY
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 1:226 E COLLEGE ST STE B
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4348
Mailing Address - Country:US
Mailing Address - Phone:678-987-1490
Mailing Address - Fax:678-987-1491
Practice Address - Street 1:226 E COLLEGE ST STE B
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4348
Practice Address - Country:US
Practice Address - Phone:678-987-1490
Practice Address - Fax:678-987-1491
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA00000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program