MEDICARE: CASSANDRA ROSE CLEMSON

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
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1750216453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSANDRA ROSE CLEMSON

Provider Business Mailing Address
First Line	:	1025 WILLOW DR
Second Line	:
City	:	ANNVILLE
State	:	PA
Zip	:	17003-1932
Country	:	US
Telephone Number	:	717-673-7836
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 WILLOW DR
Second Line	:
City	:	ANNVILLE
State	:	PA
Zip	:	17003-1932
Country	:	US
Telephone Number	:	717-673-7836
Fax Number	:

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

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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Directions to “ CASSANDRA ROSE CLEMSON ” Practice Location

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