Healthcare Provider Details

I. General information

NPI: 1164944088
Provider Name (Legal Business Name): KIANA MARIE GLEASON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 EBONY DR.
OXNARD CA
93030
US

IV. Provider business mailing address

1611 EBONY DR
OXNARD CA
93030-8637
US

V. Phone/Fax

Practice location:
  • Phone: 805-814-6206
  • Fax:
Mailing address:
  • Phone: 805-814-6206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: