MEDICARE: KELLI MARIE HIGHTSHOE ATC,R

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	1909	MN

General Provider Information

NPI Number	:	1598727349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI MARIE HIGHTSHOE ATC,R

Provider Business Mailing Address
First Line	:	13050 DAHLIA CIR
Second Line	:	#211
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-7653
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	934 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-1345
Country	:	US
Telephone Number	:	952-210-5391
Fax Number	:

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/08/2007

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