MEDICARE: KAITLYN NICOLE EDISON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	096005299	IL
2	2255A2300X	Athletic Trainer	2020035528	MO

General Provider Information

NPI Number	:	1104388958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN NICOLE EDISON

Provider Business Mailing Address
First Line	:	10717 SAINT BERNARD LN
Second Line	:
City	:	SAINT ANN
State	:	MO
Zip	:	63074-2519
Country	:	US
Telephone Number	:	314-625-1802
Fax Number	:

Provider Business Practice Location Address
First Line	:	2549 HACKMANN RD
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-5452
Country	:	US
Telephone Number	:	636-851-4900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2019
Last Update Date	:	06/18/2025

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Directions to “ KAITLYN NICOLE EDISON ” Practice Location

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