Healthcare Provider Details

I. General information

NPI: 1619338548
Provider Name (Legal Business Name): KAYLA LANGEN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 E TULLY ST
CONVOY OH
45832-8864
US

IV. Provider business mailing address

3510 COUNTRYDALE DR
FORT WAYNE IN
46815-6520
US

V. Phone/Fax

Practice location:
  • Phone: 419-749-2026
  • Fax:
Mailing address:
  • Phone: 859-394-8625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: