Healthcare Provider Details

I. General information

NPI: 1932795002
Provider Name (Legal Business Name): KATELYN STURDIVANT OBRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 SHIELDS RD
DALTON GA
30720-5069
US

IV. Provider business mailing address

1933 SHIELDS RD
DALTON GA
30720-5069
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-6628
  • Fax:
Mailing address:
  • Phone: 706-278-6628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number101058
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: