Healthcare Provider Details

I. General information

NPI: 1467722363
Provider Name (Legal Business Name): JESSICA ERIN HULDERMAN A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E UNIVERSITY AVE
LARAMIE WY
82071-2000
US

IV. Provider business mailing address

1000 E UNIVERSITY AVE
LARAMIE WY
82071-2000
US

V. Phone/Fax

Practice location:
  • Phone: 419-205-4612
  • Fax: 307-766-2112
Mailing address:
  • Phone: 419-205-4612
  • Fax: 307-766-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number45
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: