Healthcare Provider Details

I. General information

NPI: 1205165099
Provider Name (Legal Business Name): KATHRYN ANNE CARDINAL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 UNIVERSITY AVE ATTN: ATHLETICS
COLUMBUS GA
31907-5679
US

IV. Provider business mailing address

4225 UNIVERSITY AVE ATTN: ATHLETICS
COLUMBUS GA
31907-5679
US

V. Phone/Fax

Practice location:
  • Phone: 706-565-4332
  • Fax: 706-569-3435
Mailing address:
  • Phone: 706-565-4332
  • Fax: 706-569-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001704
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: