Provider Demographics
NPI:1528476801
Name:VESTA, KATHLEEN (ATC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:VESTA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 41ST AVENUE CT S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-7473
Mailing Address - Country:US
Mailing Address - Phone:701-936-1078
Mailing Address - Fax:
Practice Address - Street 1:2298 LONGSTREET RD A
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-5063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20382255A2300X
ND337-072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer