Provider Demographics
NPI:1285403378
Name:RUTHERFORD, KATIE MICHELLE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:MICHELLE
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3525 BEECHNUT CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-3215
Mailing Address - Country:US
Mailing Address - Phone:210-323-9524
Mailing Address - Fax:
Practice Address - Street 1:1404 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5028
Practice Address - Country:US
Practice Address - Phone:910-987-9338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20211225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist