=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457863078
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEA RENE KOCAN ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2017
-----------------------------------------------------
Last Update Date | 11/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 338 LEXINGTON AVE
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40506-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-928-2287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6209 SIEBERT ST
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48640-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-430-0272
-----------------------------------------------------
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 | AT1381
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------