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NPI Code Detail

MEDICARE: MRS. MELISSA KRISTINE VANGIESEN MS, ATC

MEDICARE: MRS. MELISSA KRISTINE VANGIESEN MS, ATC
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 Trainer96002127IL

General Provider Information

NPI Number : 1427022250
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MELISSA KRISTINE VANGIESEN MS, ATC
Provider Business Mailing Address
First Line : 829 W EDWARDS ST
Second Line :
City : VANDALIA
State : IL
Zip : 62471-2653
Country : US
Telephone Number : 618-283-2756
Fax Number :
Provider Business Practice Location Address
First Line : 400 N PLEASANT AVE
Second Line :
City : CENTRALIA
State : IL
Zip : 62801-3056
Country : US
Telephone Number : 618-436-8641
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/16/2006
Last Update Date : 07/08/2007

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