Provider Demographics
NPI:1629641634
Name:REITZ, KATIE MARIE MILLER
Entity Type:Individual
Prefix:
First Name:KATIE MARIE
Middle Name:MILLER
Last Name:REITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 BLU STEELE WAY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-8638
Mailing Address - Country:US
Mailing Address - Phone:443-992-3642
Mailing Address - Fax:
Practice Address - Street 1:1583 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3858
Practice Address - Country:US
Practice Address - Phone:803-329-7772
Practice Address - Fax:803-329-9821
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4809363A00000X
NC0010-13137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty