Healthcare Provider Details

I. General information

NPI: 1457371593
Provider Name (Legal Business Name): GAY LYNN ANDERSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11901 WORNALL RD AVILA UNIVERSITY, M112
KANSAS CITY MO
64145-1007
US

IV. Provider business mailing address

409 E 74TH TER
KANSAS CITY MO
64131-1636
US

V. Phone/Fax

Practice location:
  • Phone: 816-501-3742
  • Fax: 816-941-4503
Mailing address:
  • Phone: 816-786-8682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000172604
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: