Provider Demographics
NPI:1124068952
Name:DRYER, KATRINA (NP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:DRYER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2049
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-2049
Mailing Address - Country:US
Mailing Address - Phone:601-205-9994
Mailing Address - Fax:
Practice Address - Street 1:14911 N 75TH DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4394
Practice Address - Country:US
Practice Address - Phone:601-940-2570
Practice Address - Fax:480-478-0633
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2677363LP0808X, 363LF0000X
MS902459363LP0808X
WAAP61446651363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP64043Medicare UPIN
AZZ131831Medicare PIN