Healthcare Provider Details

I. General information

NPI: 1821649971
Provider Name (Legal Business Name): KATIE BUHNERKEMPE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8432 MAGNOLIA AVE
RIVERSIDE CA
92504-3297
US

IV. Provider business mailing address

11461 MAGNOLIA AVE APT 261
RIVERSIDE CA
92505-6812
US

V. Phone/Fax

Practice location:
  • Phone: 951-689-5771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: