Provider Demographics
NPI:1528699592
Name:CHAMPION, KATHERINE ANN
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 CYPRESS WOOD CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-6815
Mailing Address - Country:US
Mailing Address - Phone:361-933-6399
Mailing Address - Fax:682-499-6952
Practice Address - Street 1:4918 MABLE ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4029
Practice Address - Country:US
Practice Address - Phone:361-933-6399
Practice Address - Fax:361-933-6399
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX513969099Medicaid
TX5A10-E24-KC21OtherPESTIGE