Healthcare Provider Details

I. General information

NPI: 1861959488
Provider Name (Legal Business Name): KATIE MARIE KIMMICH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 FOREST DR SE
CEDAR RAPIDS IA
52403-1653
US

IV. Provider business mailing address

3906 B AVE NE
CEDAR RAPIDS IA
52402-5644
US

V. Phone/Fax

Practice location:
  • Phone: 319-558-2161
  • Fax:
Mailing address:
  • Phone: 319-654-6114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00627
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: