Provider Demographics
NPI:1821595273
Name:WADDELL, KATHRYN (ATC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-0767
Mailing Address - Country:US
Mailing Address - Phone:304-619-5435
Mailing Address - Fax:
Practice Address - Street 1:110 DEER XING
Practice Address - Street 2:
Practice Address - City:VONORE
Practice Address - State:TN
Practice Address - Zip Code:37885-2133
Practice Address - Country:US
Practice Address - Phone:423-884-6958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29242255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program