Provider Demographics
NPI:1629641634
Name:REITZ, KATIE MARIE MILLER
Entity type:Individual
Prefix:
First Name:KATIE MARIE
Middle Name:MILLER
Last Name:REITZ
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 1:1113 BLU STEELE WAY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-8638
Mailing Address - Country:US
Mailing Address - Phone:443-992-3642
Mailing Address - Fax:
Practice Address - Street 1:3620 ENSIGN RD NE STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-6957
Practice Address - Country:US
Practice Address - Phone:360-884-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61531628363AM0700X
NC0010-13137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant