Healthcare Provider Details

I. General information

NPI: 1417055351
Provider Name (Legal Business Name): KRISTEN MARIE LAMADELEINE ATHLETIC TRAINER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 WATERBURY RD
PROSPECT CT
06712-1200
US

IV. Provider business mailing address

166 WATERBURY RD
PROSPECT CT
06712-1200
US

V. Phone/Fax

Practice location:
  • Phone: 203-758-4118
  • Fax: 203-758-7856
Mailing address:
  • Phone: 203-758-4118
  • Fax: 203-758-7856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000035
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: