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General NPI Number Information
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NPI Number | 1932608189
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Entity Type | Individual
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Provider Name | KATHRYN HAYNES ATC
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Gender | Female
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Dates
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Enumeration Date | 02/02/2018
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Last Update Date | 02/02/2018
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Provider Practice Location Address
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Address Line | 1402 S 1ST ST
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City | CHAMPAIGN
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State | IL
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Zip | 61820-6916
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Country | US
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Telephone | 217-333-6718
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Fax |
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Provider Business Mailing Address
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Address Line | 100 VILLAGE PARK WAY APT 205
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City | SAVOY
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State | IL
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Zip | 61874-7441
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Country | US
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Telephone | 513-218-7336
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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 | 096.004230
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License Number State | IL
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