Provider Demographics
NPI:1790565711
Name:LEBOUTON, KIARA ANN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KIARA
Middle Name:ANN
Last Name:LEBOUTON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 3RD ST APT 8B
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-3258
Mailing Address - Country:US
Mailing Address - Phone:920-642-1313
Mailing Address - Fax:
Practice Address - Street 1:2400 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8728
Practice Address - Country:US
Practice Address - Phone:920-642-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3121-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer