Provider Demographics
NPI:1619297918
Name:HERBERMANN, KATHLENE (AA)
Entity Type:Individual
Prefix:
First Name:KATHLENE
Middle Name:
Last Name:HERBERMANN
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 140-214
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7247
Mailing Address - Country:US
Mailing Address - Phone:678-604-1053
Mailing Address - Fax:678-604-5548
Practice Address - Street 1:1133 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5085
Practice Address - Country:US
Practice Address - Phone:678-604-1053
Practice Address - Fax:678-604-5548
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant