Provider Demographics
NPI:1235847427
Name:CROEKER, KAITLYN ALYSSA (MS, LAT, ATC, CES)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ALYSSA
Last Name:CROEKER
Suffix:
Gender:F
Credentials:MS, LAT, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 VOLUNTEER ST APT 303
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-5183
Mailing Address - Country:US
Mailing Address - Phone:262-948-9867
Mailing Address - Fax:
Practice Address - Street 1:60 SHILOH RD
Practice Address - Street 2:
Practice Address - City:TUSCULUM
Practice Address - State:TN
Practice Address - Zip Code:37745-0595
Practice Address - Country:US
Practice Address - Phone:262-948-9867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31022255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer