Healthcare Provider Details

I. General information

NPI: 1528505047
Provider Name (Legal Business Name): KELSEY JO LANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2017
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 MAJESTIC VIEW WALK
LEXINGTON KY
40511-8882
US

IV. Provider business mailing address

3120 MAJESTIC VIEW WALK
LEXINGTON KY
40511-8882
US

V. Phone/Fax

Practice location:
  • Phone: 724-249-7822
  • Fax:
Mailing address:
  • Phone: 724-249-7822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1497
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: