Provider Demographics
NPI:1164965349
Name:STAHL, KATELYN (CAA)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:STAHL
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3484
Mailing Address - Country:US
Mailing Address - Phone:803-765-1838
Mailing Address - Fax:803-765-1732
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92367H00000X
GA8217367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant