=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093815748
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL RENEE KISTLER ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1296 TOD PL NW SUITE 208
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44485-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-306-5018
-----------------------------------------------------
Fax | 330-306-5021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1399 MILLIKIN PL NE
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44483-4451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-372-4580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 000622
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------