Healthcare Provider Details

I. General information

NPI: 1528857984
Provider Name (Legal Business Name): KATELYNN STARR THIBODEAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATELYNN STARR CLOTFELTER

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 HARDY CASH DR
HAMPTON VA
23666-2420
US

IV. Provider business mailing address

4402 LAWRENCEVILLE RD STE 225
LOGANVILLE GA
30052-6780
US

V. Phone/Fax

Practice location:
  • Phone: 757-637-4277
  • Fax: 757-299-8435
Mailing address:
  • Phone: 678-225-8858
  • Fax: 470-945-3225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2101002974
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: