=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154836773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN DEERING
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2017
-----------------------------------------------------
Last Update Date | 12/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 SOUTH ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04938-6823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-778-7147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 MARCEAU CT APT 5B
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04938-1943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-313-6321
-----------------------------------------------------
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 | AT618
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------