Healthcare Provider Details

I. General information

NPI: 1558088567
Provider Name (Legal Business Name): KATHERINE WIKING ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2022
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 HOUGHTON ST APT 1
HUDSON MA
01749-2514
US

IV. Provider business mailing address

65 HOUGHTON ST APT 1
HUDSON MA
01749-2514
US

V. Phone/Fax

Practice location:
  • Phone: 516-382-0714
  • Fax:
Mailing address:
  • Phone: 516-382-0714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3257
License Number StateMA

VII. Legacy identifiers

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

# 1
Identifier2000010108
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerN/A

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: