MEDICARE: KELSEY DIANNE CARLETON 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
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1841795135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY DIANNE CARLETON ATC

Provider Business Mailing Address
First Line	:	717 JADE ST APT B
Second Line	:
City	:	EDINBURG
State	:	TX
Zip	:	78541-5626
Country	:	US
Telephone Number	:	217-722-7697
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 W UNIVERSITY DR
Second Line	:
City	:	EDINBURG
State	:	TX
Zip	:	78539-2909
Country	:	US
Telephone Number	:	217-722-7697
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2018
Last Update Date	:	03/28/2018

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