Healthcare Provider Details

I. General information

NPI: 1699403832
Provider Name (Legal Business Name): NATASHA NICOLE GOURLEY ATC, LAT, EMT-PM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2022
Last Update Date: 08/14/2022
Certification Date: 08/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N CLEVELAND ST
MOUNT AYR IA
50854-2201
US

IV. Provider business mailing address

1260 COUNTY HIGHWAY J23
CLEARFIELD IA
50840-8814
US

V. Phone/Fax

Practice location:
  • Phone: 641-344-2707
  • Fax: 641-464-4474
Mailing address:
  • Phone: 641-344-2707
  • Fax: 641-464-4474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000693
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: