Healthcare Provider Details

I. General information

NPI: 1184775017
Provider Name (Legal Business Name): AMBER DAWN KIVETT LAT, ATC, CSCS, OTC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MAIN ST
DANVILLE IN
46122-1948
US

IV. Provider business mailing address

5727 W MCCLURE ROAD
MONROVIA IN
46157
US

V. Phone/Fax

Practice location:
  • Phone: 317-745-3420
  • Fax: 317-745-8340
Mailing address:
  • Phone: 317-996-3713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000912A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: