Healthcare Provider Details

I. General information

NPI: 1255395877
Provider Name (Legal Business Name): KIM KANDLER MED, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E GRANT ST
APPLETON WI
54911-3483
US

IV. Provider business mailing address

1312 SULLIVAN AVE
KAUKAUNA WI
54130-3238
US

V. Phone/Fax

Practice location:
  • Phone: 920-716-8139
  • Fax: 920-531-2056
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number203-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: