Provider Demographics
NPI: | 1639154099 |
---|---|
Name: | ZIMMERMAN, KATIE CRAIN (CRNP) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | KATIE |
Middle Name: | CRAIN |
Last Name: | ZIMMERMAN |
Suffix: | |
Gender: | F |
Credentials: | CRNP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3301 WOODBURN RD STE 107 |
Mailing Address - Street 2: | |
Mailing Address - City: | ANNANDALE |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 22003-1297 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3301 WOODBURN RD STE 107 |
Practice Address - Street 2: | |
Practice Address - City: | ANNANDALE |
Practice Address - State: | VA |
Practice Address - Zip Code: | 22003-1297 |
Practice Address - Country: | US |
Practice Address - Phone: | 703-876-0437 |
Practice Address - Fax: | 703-876-0722 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-08 |
Last Update Date: | 2018-03-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
LA | 03643 | 164W00000X |
VA | 0024168384 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 164W00000X | Nursing Service Providers | Licensed Practical Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
LA | 1431567 | Medicaid | |
LA | 4B4567549 | Medicare PIN | |
LA | 1431567 | Medicaid |