Healthcare Provider Details

I. General information

NPI: 1447785498
Provider Name (Legal Business Name): KAYLA STAVNES ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5858 DECATUR BLVD
INDIANAPOLIS IN
46241-9575
US

IV. Provider business mailing address

4210 WOODSAGE TRCE
INDIANAPOLIS IN
46237-1314
US

V. Phone/Fax

Practice location:
  • Phone: 317-460-5848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002886A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: