Healthcare Provider Details

I. General information

NPI: 1326932054
Provider Name (Legal Business Name): LORELEI KOTWASINSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 BEARDSHEAR HALL
AMES IA
50011-0001
US

IV. Provider business mailing address

3833 S 57TH AVE
CICERO IL
60804-4304
US

V. Phone/Fax

Practice location:
  • Phone: 515-460-5810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: