Provider Demographics
NPI:1457735896
Name:STOTTS, KATRINA RENAE (MMS)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:RENAE
Last Name:STOTTS
Suffix:
Gender:F
Credentials:MMS
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:RENAE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMS
Mailing Address - Street 1:1001 SAM PERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4453
Mailing Address - Country:US
Mailing Address - Phone:540-741-1571
Mailing Address - Fax:540-361-7010
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4453
Practice Address - Country:US
Practice Address - Phone:540-741-1571
Practice Address - Fax:540-361-7010
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-004999363AM0700X
VA0110004999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant