Provider Demographics
NPI:1871832881
Name:KATANA, VIENNA GRAYCE (DO)
Entity type:Individual
Prefix:DR
First Name:VIENNA
Middle Name:GRAYCE
Last Name:KATANA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4664 N PENNGROVE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7442
Mailing Address - Country:US
Mailing Address - Phone:208-898-7467
Mailing Address - Fax:208-398-2120
Practice Address - Street 1:4664 N PENNGROVE WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7442
Practice Address - Country:US
Practice Address - Phone:208-898-7467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13629207N00000X
390200000X
CA13629207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program