Provider Demographics
NPI:1295551240
Name:KINGSMORE, KONNOR GERALD (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KONNOR
Middle Name:GERALD
Last Name:KINGSMORE
Suffix:
Gender:M
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:W64N14273 WASHINGTON AVE APT 129
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-3035
Mailing Address - Country:US
Mailing Address - Phone:719-510-5126
Mailing Address - Fax:
Practice Address - Street 1:N91W15750 FALLS PKWY
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2301
Practice Address - Country:US
Practice Address - Phone:262-532-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3219-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer