Healthcare Provider Details

I. General information

NPI: 1306470042
Provider Name (Legal Business Name): KATHERINE ANNE UPCHURCH MS, ATC, CSCS, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE UPCHURCH MS,ATC, CSCS, LAT

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6191 PARK AVE
MEMPHIS TN
38119-5399
US

IV. Provider business mailing address

6191 PARK AVE
MEMPHIS TN
38119-5399
US

V. Phone/Fax

Practice location:
  • Phone: 901-260-1378
  • Fax:
Mailing address:
  • Phone: 901-260-1378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1209
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: