Provider Demographics
NPI:1609037100
Name:GHANAYEM, KATHERINE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ANN
Last Name:GHANAYEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:ANN
Other - Last Name:KNOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9445 N BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-9059
Mailing Address - Country:US
Mailing Address - Phone:701-471-9606
Mailing Address - Fax:
Practice Address - Street 1:4400 HERITAGE TRACE PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8901
Practice Address - Country:US
Practice Address - Phone:701-471-9606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ0952208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program