Healthcare Provider Details

I. General information

NPI: 1609221613
Provider Name (Legal Business Name): KATINA GIBBNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 VALLEY RD
SCHELLSBURG PA
15559-9106
US

IV. Provider business mailing address

2316 VALLEY RD
SCHELLSBURG PA
15559-9106
US

V. Phone/Fax

Practice location:
  • Phone: 814-839-0096
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT001951A
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: