Provider Demographics
NPI:1679567150
Name:HERNDON, KATHRYN ELAINE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ELAINE
Last Name:HERNDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 SPRING ST SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3740
Mailing Address - Country:US
Mailing Address - Phone:770-503-7222
Mailing Address - Fax:770-718-0009
Practice Address - Street 1:530 SPRING ST SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3740
Practice Address - Country:US
Practice Address - Phone:770-503-7222
Practice Address - Fax:770-718-0009
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA03279174400000X
GA032749207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No174400000XOther Service ProvidersSpecialist
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE99458Medicare UPIN
722BBBBXMedicare ID - Type Unspecified