Provider Demographics
NPI:1265242317
Name:FISHTROM, KATELYN JOY
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:JOY
Last Name:FISHTROM
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 1:1396 HERMOSA AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-4144
Mailing Address - Country:US
Mailing Address - Phone:650-868-6938
Mailing Address - Fax:
Practice Address - Street 1:1396 HERMOSA AVE
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-4144
Practice Address - Country:US
Practice Address - Phone:650-868-6938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula