Provider Demographics
NPI:1699195412
Name:RUSTERHOLTZ, KAYLA DAWN (MS, ATC)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:DAWN
Last Name:RUSTERHOLTZ
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4682 LAKE VALLEY DR APT 2B
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4682 LAKE VALLEY DR APT 2B
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1449
Practice Address - Country:US
Practice Address - Phone:972-978-1854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-19
Last Update Date:2014-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0032402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer