Provider Demographics
NPI:1902373343
Name:HAVRILLA, KRISTEN (PA-C)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:
Last Name:HAVRILLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 AVERY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2313
Mailing Address - Country:US
Mailing Address - Phone:404-791-3772
Mailing Address - Fax:
Practice Address - Street 1:6660 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-3167
Practice Address - Country:US
Practice Address - Phone:404-996-0195
Practice Address - Fax:404-531-0967
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022680363A00000X
GA12434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant