Healthcare Provider Details

I. General information

NPI: 1669843363
Provider Name (Legal Business Name): BIANCA BAUTISTA WALKER-GUNDOLFF AT. ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2168 FIELD HOUSE DR
USAF ACADEMY CO
80840-9599
US

IV. Provider business mailing address

2168 FIELD HOUSE DR
USAF ACADEMY CO
80840-9599
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-0204
  • Fax:
Mailing address:
  • Phone: 719-333-0204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0002746
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-0969
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.004832
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: