Healthcare Provider Details

I. General information

NPI: 1720353782
Provider Name (Legal Business Name): KATIE ANN DAGGETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 US 51 SOUTH SUITE A
COVINGTON TN
38019
US

IV. Provider business mailing address

1618 US 51 SOUTH SUITE A
COVINGTON TN
38019
US

V. Phone/Fax

Practice location:
  • Phone: 901-313-9274
  • Fax:
Mailing address:
  • Phone: 901-313-9274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2116
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00181
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: