Provider Demographics
NPI:1356172712
Name:WARNECKE, KAT (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KAT
Middle Name:
Last Name:WARNECKE
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-5041
Mailing Address - Country:US
Mailing Address - Phone:208-577-0130
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-9803
Practice Address - Country:US
Practice Address - Phone:208-577-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-9172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer