Healthcare Provider Details

I. General information

NPI: 1093556581
Provider Name (Legal Business Name): CAITLIN ROSE ANTISDEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 186TH ST APT 300
WESTFIELD IN
46074-2002
US

IV. Provider business mailing address

1531 E NORTHFIELD DR
BROWNSBURG IN
46112-2513
US

V. Phone/Fax

Practice location:
  • Phone: 317-804-3501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36004225A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: