Provider Demographics
NPI:1831662956
Name:REAVIS, KAITLYN MARIE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:REAVIS
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 1:137 GLENN ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-5809
Mailing Address - Country:US
Mailing Address - Phone:704-677-6201
Mailing Address - Fax:
Practice Address - Street 1:137 GLENN ALLEN RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-5809
Practice Address - Country:US
Practice Address - Phone:704-677-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer