Provider Demographics
NPI:1053890699
Name:CHAMP, CAITLYN E
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:E
Last Name:CHAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13102 WHITEHALL AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060-9109
Mailing Address - Country:US
Mailing Address - Phone:816-204-4162
Mailing Address - Fax:
Practice Address - Street 1:13102 WHITEHALL AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-9109
Practice Address - Country:US
Practice Address - Phone:816-204-4162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer