Healthcare Provider Details

I. General information

NPI: 1083189674
Provider Name (Legal Business Name): KELLY QUACKENBUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 34TH ST W
BRADENTON FL
34210-3506
US

IV. Provider business mailing address

22830 COLLRIDGE DR
LAND O LAKES FL
34639-4075
US

V. Phone/Fax

Practice location:
  • Phone: 941-739-7476
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL3807
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: