Healthcare Provider Details

I. General information

NPI: 1447690672
Provider Name (Legal Business Name): CORINNE ELIZABETH GADDIS ATC, ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 SE BISHOP BLVD SUITE 120
PULLMAN WA
99163-5517
US

IV. Provider business mailing address

413 NW NORTH ST
PULLMAN WA
99163-3632
US

V. Phone/Fax

Practice location:
  • Phone: 509-332-2828
  • Fax: 509-334-7474
Mailing address:
  • Phone: 360-672-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA160251276
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-459
License Number StateID

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: