Provider Demographics
NPI:1205597465
Name:STEWART, KATHRYN ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ELIZABETH
Other - Last Name:KRAJENTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3580 JOSEPH SIEWICK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1717
Mailing Address - Country:US
Mailing Address - Phone:248-842-8816
Mailing Address - Fax:
Practice Address - Street 1:3580 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1717
Practice Address - Country:US
Practice Address - Phone:703-970-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-09
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12586363A00000X
390200000X
VA0110009210363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program