MEDICARE: MS. KATINA PONDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant	E5D5P2C7	GA
2	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1538525258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATINA PONDER

Provider Business Mailing Address
First Line	:	70 TREVITT DR APT E
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-7266
Country	:	US
Telephone Number	:	404-884-9090
Fax Number	:

Provider Business Practice Location Address
First Line	:	70 TREVITT DR APT E
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-7266
Country	:	US
Telephone Number	:	404-884-9090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2016
Last Update Date	:	01/12/2016

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