MEDICARE: KATHLEEN VESTA 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
1	2255A2300X	Athletic Trainer	2038	MN

General Provider Information

NPI Number	:	1528476801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN VESTA ATC

Provider Business Mailing Address
First Line	:	3037 41ST AVENUE CT S
Second Line	:
City	:	MOORHEAD
State	:	MN
Zip	:	56560-7473
Country	:	US
Telephone Number	:	701-936-1078
Fax Number	:

Provider Business Practice Location Address
First Line	:	2298 LONGSTREET RD A
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-0001
Country	:	US
Telephone Number	:	910-907-5063
Fax Number	:

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

Provider Enumeration Date	:	07/30/2014
Last Update Date	:	07/27/2022

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