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NPI Code Detail

MEDICARE: KATHLEEN VESTA ATC

MEDICARE: KATHLEEN VESTA ATC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer2038MN

General Provider Information

NPI Number : 1528476801
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHLEEN VESTA ATC
Provider Business Mailing Address
First Line : 3037 41ST AVENUE CT S
Second Line :
City : MOORHEAD
State : MN
Zip : 56560-7473
Country : US
Telephone Number : 701-936-1078
Fax Number :
Provider Business Practice Location Address
First Line : 2298 LONGSTREET RD A
Second Line :
City : FORT BRAGG
State : NC
Zip : 28310-0001
Country : US
Telephone Number : 910-907-5063
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/30/2014
Last Update Date : 07/27/2022

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Directions to “ KATHLEEN VESTA ATC” Practice Location

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