Healthcare Provider Details

I. General information

NPI: 1922077213
Provider Name (Legal Business Name): KATHY W HOLLOMON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MIDDLE CREEK PARK AVE
APEX NC
27539-7983
US

IV. Provider business mailing address

3020 WHITE CLOUD CIR
APEX NC
27502-4065
US

V. Phone/Fax

Practice location:
  • Phone: 919-661-5474
  • Fax:
Mailing address:
  • Phone: 919-306-9977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0442
License Number StateNC

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: