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General NPI Number Information
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NPI Number | 1104388958
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Entity Type | Individual
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Provider Name | KAITLYN NICOLE EDISON
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Gender | Female
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Dates
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Enumeration Date | 04/02/2019
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Last Update Date | 06/18/2025
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Provider Practice Location Address
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Address Line | 2549 HACKMANN RD
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City | SAINT CHARLES
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State | MO
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Zip | 63303-5452
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Country | US
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Telephone | 636-851-4900
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Fax |
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Provider Business Mailing Address
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Address Line | 10717 SAINT BERNARD LN
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City | SAINT ANN
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State | MO
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Zip | 63074-2519
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Country | US
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Telephone | 314-625-1802
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096005299
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2020035528
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License Number State | MO
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