Healthcare Provider Details

I. General information

NPI: 1184748345
Provider Name (Legal Business Name): KENT JOSHUA HULNICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KENT JOSHUA HULNICK ATC

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 S LAKES DR
RESTON VA
20191-4102
US

IV. Provider business mailing address

1414 ESPLANADE CT #147
RESTON VA
20194-1259
US

V. Phone/Fax

Practice location:
  • Phone: 703-715-4649
  • Fax:
Mailing address:
  • Phone: 703-668-0079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000923
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: