Healthcare Provider Details

I. General information

NPI: 1639767833
Provider Name (Legal Business Name): KATHRYN ANNE KOENIG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EXECUTIVE PARK DR NE
ATLANTA GA
30329-2206
US

IV. Provider business mailing address

12 EXECUTIVE PARK DR NE
ATLANTA GA
30329-2206
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-7533
  • Fax:
Mailing address:
  • Phone: 404-712-7533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN259861
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN259861
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: