=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467995480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PENNY GILBERT ATC, LAT, EMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2016
-----------------------------------------------------
Last Update Date | 11/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CESSNA BLVD HEALTH SERVICES
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67215-1400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-517-2746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7704 DEPARTMENT 832
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67277-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-517-2746
-----------------------------------------------------
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 | 24-00129
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------