Healthcare Provider Details

I. General information

NPI: 1083609903
Provider Name (Legal Business Name): KRISTEN M STREETER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 S NEIL ST
CHAMPAIGN IL
61820-7220
US

IV. Provider business mailing address

2040 S NEIL ST
CHAMPAIGN IL
61820-7220
US

V. Phone/Fax

Practice location:
  • Phone: 217-352-3330
  • Fax: 217-352-4616
Mailing address:
  • Phone: 217-352-3330
  • Fax: 217-352-4616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096-001120
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: