Provider Demographics
NPI:1194512061
Name:MARY, KATHARYN
Entity type:Individual
Prefix:
First Name:KATHARYN
Middle Name:
Last Name:MARY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-5809
Mailing Address - Country:US
Mailing Address - Phone:601-543-5742
Mailing Address - Fax:
Practice Address - Street 1:2214 5TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-5809
Practice Address - Country:US
Practice Address - Phone:601-543-5742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant