MEDICARE: HEIDI NEITZKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT841	KY

General Provider Information

NPI Number	:	1275878852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI NEITZKE

Provider Business Mailing Address
First Line	:	2001 NEWBURG RD
Second Line	:	KNIGHTS HALL
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-1863
Country	:	US
Telephone Number	:	502-272-8379
Fax Number	:	502-272-7341

Provider Business Practice Location Address
First Line	:	2001 NEWBURG RD
Second Line	:	KNIGHTS HALL
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-1863
Country	:	US
Telephone Number	:	502-272-8379
Fax Number	:	502-272-7341

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2012
Last Update Date	:	12/07/2012

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Directions to “ HEIDI NEITZKE ” Practice Location

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