Provider Demographics
NPI:1770023244
Name:DECKER, KATELYNN
Entity Type:Individual
Prefix:
First Name:KATELYNN
Middle Name:
Last Name:DECKER
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 1:428 W MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2747
Mailing Address - Country:US
Mailing Address - Phone:681-260-0818
Mailing Address - Fax:
Practice Address - Street 1:428 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2747
Practice Address - Country:US
Practice Address - Phone:681-260-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00700024108Medicaid