Healthcare Provider Details

I. General information

NPI: 1497190979
Provider Name (Legal Business Name): KATHERINE ETHRIDGE SPEIGHT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MARGIE DRIVE
WARNER ROBINS GA
31088
US

IV. Provider business mailing address

301 MARGIE DRIVE
WARNER ROBINS GA
31088
US

V. Phone/Fax

Practice location:
  • Phone: 478-971-1153
  • Fax: 178-971-1173
Mailing address:
  • Phone: 478-971-1153
  • Fax: 178-971-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006797
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: