Healthcare Provider Details

I. General information

NPI: 1609441104
Provider Name (Legal Business Name): KAYLEE MAE HULL MAT, AT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 MAUMEE WESTERN RD
MONCLOVA OH
43542-9330
US

IV. Provider business mailing address

8700 MAUMEE WESTERN RD
MONCLOVA OH
43542-9330
US

V. Phone/Fax

Practice location:
  • Phone: 419-450-2171
  • Fax:
Mailing address:
  • Phone: 419-450-2171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT006807
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: