Provider Demographics
NPI:1932795002
Name:OBRIEN, KATELYN STURDIVANT
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:STURDIVANT
Last Name:OBRIEN
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 1:1933 SHIELDS RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-5069
Mailing Address - Country:US
Mailing Address - Phone:706-278-6628
Mailing Address - Fax:
Practice Address - Street 1:1933 SHIELDS RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-5069
Practice Address - Country:US
Practice Address - Phone:706-278-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA101058208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program