Healthcare Provider Details

I. General information

NPI: 1033881156
Provider Name (Legal Business Name): ASHLEY KUDLA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S RANDALL RD
ALGONQUIN IL
60102-5944
US

IV. Provider business mailing address

3424 SOUTHPORT DR
ISLAND LAKE IL
60042-9123
US

V. Phone/Fax

Practice location:
  • Phone: 779-771-7000
  • Fax:
Mailing address:
  • Phone: 847-323-4603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.004178
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: