Provider Demographics
NPI:1194194209
Name:TRUNK, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:TRUNK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:
Other - Last Name:EDERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:417 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W892 HWY 96
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130
Practice Address - Country:US
Practice Address - Phone:920-809-8159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2101-392255A2300X
390200000X
WI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program