=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215747498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN EDWARDS ATC-L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2025
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 24TH ST
-----------------------------------------------------
City | FT GREGGADAMS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23801-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-734-5300
-----------------------------------------------------
Fax | 877-874-1008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | KENNER ARMY HEALTH CLINIC 700 24TH ST
-----------------------------------------------------
City | FT GREGG ADAMS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-734-5300
-----------------------------------------------------
Fax | 877-874-1008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 070202128
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------