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NPI Code Detail

MEDICARE: NICOLE LYNN BALDERSTON MS, LAT, ATC

MEDICARE: NICOLE LYNN BALDERSTON MS, LAT, ATC
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
12255A2300XAthletic Trainer2019032463MO
22255A2300XAthletic Trainer24-01454KS

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12019032463OTHERMOAT LINCENSE
224-01454OTHERKSAT LICENSE
32000015152OTHERNATA BOC

General Provider Information

NPI Number : 1205532819
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE LYNN BALDERSTON MS, LAT, ATC
Provider Business Mailing Address
First Line : 5625 W 134TH PL APT 2037
Second Line :
City : OVERLAND PARK
State : KS
Zip : 66209-4064
Country : US
Telephone Number : 785-819-1129
Fax Number :
Provider Business Practice Location Address
First Line : 1950 DIAMOND PKWY
Second Line :
City : KANSAS CITY
State : MO
Zip : 64116-4328
Country : US
Telephone Number : 816-561-3003
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/06/2023
Last Update Date : 02/06/2023

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