Healthcare Provider Details

I. General information

NPI: 1902890460
Provider Name (Legal Business Name): LORI CLAYTON MS, ATC, PES
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 GUNDERSEN DR
ONALASKA WI
54650
US

IV. Provider business mailing address

W5976 COUNTY RD S
ONALASKA WI
54650-8662
US

V. Phone/Fax

Practice location:
  • Phone: 608-775-9402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00093
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number674-039
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1824
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: