Healthcare Provider Details

I. General information

NPI: 1396659876
Provider Name (Legal Business Name): QUENTON THOMAS GELLIN LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E EMMERS DR
APPLETON WI
54915-3802
US

IV. Provider business mailing address

2600 FOREST VIEW CT APT 8
APPLETON WI
54915-6235
US

V. Phone/Fax

Practice location:
  • Phone: 920-852-5400
  • Fax:
Mailing address:
  • Phone: 920-819-0826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number328639
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: