Provider Demographics
NPI:1538673058
Name:POINDEXTER, KATHERINE WILEY (PA-C, RDN)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:WILEY
Last Name:POINDEXTER
Suffix:
Gender:F
Credentials:PA-C, RDN
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:MARGARET
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2346 JOSE CIR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-3547
Mailing Address - Country:US
Mailing Address - Phone:404-290-1456
Mailing Address - Fax:
Practice Address - Street 1:2804 SAINT JOHNS BLUFF RD S STE 109
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-3777
Practice Address - Country:US
Practice Address - Phone:904-727-9123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004401133V00000X
FLND7238133V00000X
FLPA9110905207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered