Provider Demographics
NPI:1629727664
Name:DEAN, KATHERINE DONOVAN (C-PNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DONOVAN
Last Name:DEAN
Suffix:
Gender:F
Credentials:C-PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 TOWN BLVD NE APT 472
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3081
Mailing Address - Country:US
Mailing Address - Phone:901-463-0784
Mailing Address - Fax:
Practice Address - Street 1:3025 KATE BOND RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4004
Practice Address - Country:US
Practice Address - Phone:901-384-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31467363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics