=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316651060
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KALYN POWELL ATC, LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2023
-----------------------------------------------------
Last Update Date | 04/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 CROWN CT
-----------------------------------------------------
City | STUYVESANT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12173-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-506-0890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 105
-----------------------------------------------------
City | STUYVESANT FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12174-0105
-----------------------------------------------------
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 |
-----------------------------------------------------