Provider Demographics
NPI:1780458976
Name:PROPHETER, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:PROPHETER
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 1:2699 W 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97448-8363
Mailing Address - Country:US
Mailing Address - Phone:915-261-2184
Mailing Address - Fax:
Practice Address - Street 1:3333 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-222-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202112788RN163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn