Provider Demographics
NPI:1821581612
Name:DIRKS, KATHRYN GRETCHEN (CNM)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:GRETCHEN
Last Name:DIRKS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 PARK AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-3452
Mailing Address - Country:US
Mailing Address - Phone:440-935-5719
Mailing Address - Fax:
Practice Address - Street 1:5780 PEACHTREE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1554
Practice Address - Country:US
Practice Address - Phone:404-255-8022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACNM04860176B00000X
GARN261804363LF0000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily