Provider Demographics
NPI:1447761770
Name:KITSMILLER, IZAAC (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:IZAAC
Middle Name:
Last Name:KITSMILLER
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-1648
Mailing Address - Country:US
Mailing Address - Phone:308-383-3716
Mailing Address - Fax:
Practice Address - Street 1:3215 CUMING ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2000
Practice Address - Country:US
Practice Address - Phone:308-383-3716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty