Healthcare Provider Details

I. General information

NPI: 1104274851
Provider Name (Legal Business Name): KAITLIN CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 N ALLEN RD
PEORIA IL
61614-3294
US

IV. Provider business mailing address

6000 N ALLEN RD
PEORIA IL
61614-3294
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-1400
  • Fax: 309-693-3197
Mailing address:
  • Phone: 309-691-1400
  • Fax: 309-689-7094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: