MEDICARE: KELLY L ENFIELD ATC/L

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		WA

General Provider Information

NPI Number	:	1558637868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L ENFIELD ATC/L

Provider Business Mailing Address
First Line	:	17026 426TH AVE SE
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045-9345
Country	:	US
Telephone Number	:	425-736-1475
Fax Number	:

Provider Business Practice Location Address
First Line	:	17050 431ST AVE SE
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045-9650
Country	:	US
Telephone Number	:	425-736-1475
Fax Number	:

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

Provider Enumeration Date	:	03/30/2012
Last Update Date	:	06/11/2014

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