Provider Demographics
NPI:1720495021
Name:OUTLAW, KATIA FAYOLA
Entity Type:Individual
Prefix:
First Name:KATIA
Middle Name:FAYOLA
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5582 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3215
Mailing Address - Country:US
Mailing Address - Phone:404-307-4445
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE STE 1600
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2246
Practice Address - Country:US
Practice Address - Phone:404-298-8998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704254995163W00000X, 363LF0000X
NC281863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3723Medicaid
NC1720495021Medicaid
SCNP3723Medicaid
NC1720495021Medicaid
NCNCR920DMedicare PIN
NCNCR920EMedicare PIN
NCNCR920CMedicare PIN