Provider Demographics
NPI:1568490928
Name:MINER, KATIE (NP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MINER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 N OAK STREET EXT
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-242-6061
Mailing Address - Fax:229-242-6151
Practice Address - Street 1:3301 N OAK STREET EXT
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1014
Practice Address - Country:US
Practice Address - Phone:229-242-6061
Practice Address - Fax:229-242-6151
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA140594363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000954236DMedicaid
GA000954236BMedicaid
GA000954236AMedicaid
GA000954236CMedicaid