Healthcare Provider Details

I. General information

NPI: 1730173303
Provider Name (Legal Business Name): KIMBERLY LYNNE VICTORA ATC, CSCS, PES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY LYNNE ZIRBEL ATC, CSCS, PES

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 GUNDERSEN DR NC1-002
ONALASKA WI
54650-8447
US

IV. Provider business mailing address

114 GRISWOLD AVE
WEST SALEM WI
54669-9284
US

V. Phone/Fax

Practice location:
  • Phone: 608-775-8600
  • Fax:
Mailing address:
  • Phone: 608-775-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1562
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number221-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: