=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144741471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY WILSON-GUSTAFSON MA, LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2017
-----------------------------------------------------
Last Update Date | 06/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 SNAFFLE BIT DR
-----------------------------------------------------
City | GARDNERVILLE
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89410-5892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-283-1710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 SNAFFLE BIT DR
-----------------------------------------------------
City | GARDNERVILLE
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89410-5892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------