Healthcare Provider Details

I. General information

NPI: 1316474331
Provider Name (Legal Business Name): KAYLA WINCKO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 WISTERIA ST
RUSTON LA
71272-0001
US

IV. Provider business mailing address

4744 NW 5TH PL
COCONUT CREEK FL
33063-6742
US

V. Phone/Fax

Practice location:
  • Phone: 954-864-5007
  • Fax:
Mailing address:
  • Phone: 954-864-5007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier22
Identifier TypeOTHER
Identifier State
Identifier IssuerRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: