Healthcare Provider Details

I. General information

NPI: 1780047027
Provider Name (Legal Business Name): NICOLE ELIZABETH TRUMPOLD ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 1ST AVE NE EBY FIELDHOUSE
CEDAR RAPIDS IA
52402-5008
US

IV. Provider business mailing address

650 COLTON CIR NE UNIT 11
CEDAR RAPIDS IA
52402-6760
US

V. Phone/Fax

Practice location:
  • Phone: 319-361-3490
  • Fax:
Mailing address:
  • Phone: 319-361-3490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000947
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: