Healthcare Provider Details

I. General information

NPI: 1275088122
Provider Name (Legal Business Name): KATY FELLOWS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CANYON RD APT 1303
LOS ALAMOS NM
87544-6215
US

IV. Provider business mailing address

3200 CANYON RD APT 1303
LOS ALAMOS NM
87544-6215
US

V. Phone/Fax

Practice location:
  • Phone: 530-263-3801
  • Fax:
Mailing address:
  • Phone: 530-263-3801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: