Provider Demographics
NPI:1922503622
Name:YOUNG, KATHERINE DIANE (FNP C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DIANE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:FNP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4340 LAKESIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-7908
Mailing Address - Country:US
Mailing Address - Phone:770-596-4986
Mailing Address - Fax:
Practice Address - Street 1:4181 HOSPITAL DR NE STE 401
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2541
Practice Address - Country:US
Practice Address - Phone:404-778-1153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAFO1180184363LP2300X
GARN185371363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care