Healthcare Provider Details

I. General information

NPI: 1497122881
Provider Name (Legal Business Name): KYLE ANDRE ST. PETER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 UNIVERSITY DR, MS 3A5
FAIRFAX VA
22030
US

IV. Provider business mailing address

11318 WESTBROOK MILL LN UNIT 103
FAIRFAX VA
22030-5665
US

V. Phone/Fax

Practice location:
  • Phone: 703-993-3280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001718
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number3203056420
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126003666
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: