Provider Demographics
NPI:1568417723
Name:HERRON, KATRINA ELISE (PT)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:ELISE
Last Name:HERRON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11421 E DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-2343
Mailing Address - Country:US
Mailing Address - Phone:480-354-2911
Mailing Address - Fax:480-984-3169
Practice Address - Street 1:11421 E DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-2343
Practice Address - Country:US
Practice Address - Phone:480-354-2911
Practice Address - Fax:480-984-3169
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6133225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ108120Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION