MEDICARE: KAITLYN ALEXANDRA GRAYBILL ATC, VATL

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	0126002459	VA

General Provider Information

NPI Number	:	1316399884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN ALEXANDRA GRAYBILL ATC, VATL

Provider Business Mailing Address
First Line	:	11204 BRADDOCK RD
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-5405
Country	:	US
Telephone Number	:	703-273-8787
Fax Number	:

Provider Business Practice Location Address
First Line	:	11204 BRADDOCK RD
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-5405
Country	:	US
Telephone Number	:	703-273-8787
Fax Number	:

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

Provider Enumeration Date	:	07/08/2016
Last Update Date	:	03/17/2018

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