Healthcare Provider Details

I. General information

NPI: 1477205474
Provider Name (Legal Business Name): KATLYN JOHNSON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E NORTHWEST HWY
MOUNT PROSPECT IL
60056-3223
US

IV. Provider business mailing address

4547 N KARLOV AVE
CHICAGO IL
60630-4401
US

V. Phone/Fax

Practice location:
  • Phone: 847-718-9201
  • Fax:
Mailing address:
  • Phone: 773-383-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096005233
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: