Healthcare Provider Details

I. General information

NPI: 1902731516
Provider Name (Legal Business Name): KATHERINE LOUISE BACON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 MERCER UNIVERSITY DR
ATLANTA GA
30341-4115
US

IV. Provider business mailing address

568 SAINT CATHERINE CIR
RICHMOND HILL GA
31324-6520
US

V. Phone/Fax

Practice location:
  • Phone: 678-547-6778
  • Fax: 678-547-6202
Mailing address:
  • Phone: 912-312-0294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: