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NPI Code Detail

MEDICARE: LAUREN A WILLIE LAT, ATC, MAT

MEDICARE: LAUREN A WILLIE LAT, ATC, MAT
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
12255A2300XAthletic TrainerAT004188GA

General Provider Information

NPI Number : 1356065270
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAUREN A WILLIE LAT, ATC, MAT
Provider Business Mailing Address
First Line : 522 LEE ROAD 613
Second Line :
City : SMITHS STATION
State : AL
Zip : 36877-2004
Country : US
Telephone Number : 251-716-2109
Fax Number :
Provider Business Practice Location Address
First Line : 6649 VIBBERT AVE
Second Line :
City : FORT BENNING
State : GA
Zip : 31905-4464
Country : US
Telephone Number : 251-716-2109
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2022
Last Update Date : 10/04/2022

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Directions to “ LAUREN A WILLIE LAT, ATC, MAT” Practice Location

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