Healthcare Provider Details

I. General information

NPI: 1003261900
Provider Name (Legal Business Name): KATELYN STAHNKE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 CURVE CREST BLVD W
STILLWATER MN
55082-6040
US

IV. Provider business mailing address

1500 CURVE CREST BLVD W
STILLWATER MN
55082-6040
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-1234
  • Fax:
Mailing address:
  • Phone: 651-439-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2432
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: