Provider Demographics
NPI:1013490614
Name:GULBRANSON, KORLYN (ATC)
Entity Type:Individual
Prefix:
First Name:KORLYN
Middle Name:
Last Name:GULBRANSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 N 200 E APT 4
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-2939
Mailing Address - Country:US
Mailing Address - Phone:801-935-0048
Mailing Address - Fax:
Practice Address - Street 1:123 SAB APT 4
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602-1547
Practice Address - Country:US
Practice Address - Phone:801-935-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10933369-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer