Healthcare Provider Details

I. General information

NPI: 1669183174
Provider Name (Legal Business Name): CIERRA DAWN BRUMBACK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 HORTON ST
FORT SCOTT KS
66701-3141
US

IV. Provider business mailing address

724 N OSAGE ST
GIRARD KS
66743-1016
US

V. Phone/Fax

Practice location:
  • Phone: 620-644-6086
  • Fax:
Mailing address:
  • Phone: 620-249-4049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01864
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: