Healthcare Provider Details

I. General information

NPI: 1619491487
Provider Name (Legal Business Name): KELSEY DESHAMBO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 IRVING SCHOTTENSTEIN DR
COLUMBUS OH
43210-1044
US

IV. Provider business mailing address

2344 ANTIGUA DR APT 3A
COLUMBUS OH
43235-6148
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-1165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT005429
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: