Healthcare Provider Details

I. General information

NPI: 1407239346
Provider Name (Legal Business Name): CARLIE KATE ELMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9551 SIJAN AVE
JBER AK
99506-4300
US

IV. Provider business mailing address

7125 E SUPERSTITION SPRINGS BLVD
MESA AZ
85209-4032
US

V. Phone/Fax

Practice location:
  • Phone: 609-540-2040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1409
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number165528
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: