Provider Demographics
NPI:1699552422
Name:MAYRY, KATHERINE J (AC-PNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:J
Last Name:MAYRY
Suffix:
Gender:F
Credentials:AC-PNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:J
Other - Last Name:NICKDOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:434-295-1000
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-924-3627
Practice Address - Fax:434-924-3300
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0024188286363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program