Healthcare Provider Details

I. General information

NPI: 1780131458
Provider Name (Legal Business Name): KATHRYN DELOST BS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 OLD MAIN HL
LOGAN UT
84322-7425
US

IV. Provider business mailing address

1651 N 400 E APT 639
LOGAN UT
84341-5664
US

V. Phone/Fax

Practice location:
  • Phone: 435-797-3636
  • Fax:
Mailing address:
  • Phone: 703-989-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number9468273-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: