MEDICARE: TIFFANY JOHNSON LAT, 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
1	2255A2300X	Athletic Trainer	AT7592	TX

General Provider Information

NPI Number	:	1669915880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY JOHNSON LAT, ATC

Provider Business Mailing Address
First Line	:	424 LANCASTER AVE APT 2
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17603-3310
Country	:	US
Telephone Number	:	302-373-2458
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 RIVER RD
Second Line	:
City	:	CONESTOGA
State	:	PA
Zip	:	17516-9327
Country	:	US
Telephone Number	:	717-842-2321
Fax Number	:

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

Provider Enumeration Date	:	11/19/2016
Last Update Date	:	04/07/2022

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