Healthcare Provider Details

I. General information

NPI: 1962805655
Provider Name (Legal Business Name): KATHY STOMPRO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 25TH ST S
FARGO ND
58103-6104
US

IV. Provider business mailing address

2625 39TH AVE S
FARGO ND
58104-7026
US

V. Phone/Fax

Practice location:
  • Phone: 701-237-9712
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number045-87
License Number StateND

VII. Legacy identifiers

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

# 1
Identifier045-87
Identifier TypeOTHER
Identifier StateND
Identifier IssuerNDATA
# 2
Identifier000050628
Identifier TypeOTHER
Identifier State
Identifier IssuerNATA BOC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: