Provider Demographics
NPI:1770136574
Name:DEBERRY, KATELYN ANN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ANN
Last Name:DEBERRY
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 1:3721 CAPE YORK TRCE
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-6433
Mailing Address - Country:US
Mailing Address - Phone:678-215-5528
Mailing Address - Fax:
Practice Address - Street 1:1800 NORTHSIDE FORSYTH DR STE 450
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8483
Practice Address - Country:US
Practice Address - Phone:770-442-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-20
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant