Healthcare Provider Details

I. General information

NPI: 1164893301
Provider Name (Legal Business Name): KATHERINE STAGNO A.T.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S CLEARVIEW PKWY
JEFFERSON LA
70121-1011
US

IV. Provider business mailing address

2008 ABADIE AVE
METAIRIE LA
70003-4612
US

V. Phone/Fax

Practice location:
  • Phone: 504-736-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.200427
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: