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General NPI Number Information
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NPI Number | 1780239806
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Entity Type | Individual
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Provider Name | STACEY KISIL ATC, CAT(C), CSCS
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Gender | Female
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Dates
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Enumeration Date | 08/06/2019
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Last Update Date | 08/06/2019
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Provider Practice Location Address
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Address Line | 100 SMITH ST
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City | ATHENS
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State | GA
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Zip | 30602-1505
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Country | US
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Telephone | 706-296-2765
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Fax |
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Provider Business Mailing Address
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Address Line | 1188 GARDEN ROAD
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City | MISSISSAUGA
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State | ONTARIO
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Zip | L5H 3J6
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Country | CA
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AHY-881471003
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License Number State | GA
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