Healthcare Provider Details

I. General information

NPI: 1174164271
Provider Name (Legal Business Name): ABIGAIL WALDO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 DAIRY DR BOHLER ATHLETIC COMPLEX M4
PULLMAN WA
99164-5422
US

IV. Provider business mailing address

PO BOX 489
ALBION WA
99102-0489
US

V. Phone/Fax

Practice location:
  • Phone: 509-335-0319
  • Fax:
Mailing address:
  • Phone: 253-737-8275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002006
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA161269324
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: