MEDICARE: KRISTEN ANN MANDICZ 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		NJ

General Provider Information

NPI Number	:	1760018006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN ANN MANDICZ LAT, ATC

Provider Business Mailing Address
First Line	:	119 CANAL WAY
Second Line	:
City	:	HACKETTSTOWN
State	:	NJ
Zip	:	07840-1266
Country	:	US
Telephone Number	:	908-892-1952
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 JACKSON VALLEY RD
Second Line	:
City	:	WASHINGTON
State	:	NJ
Zip	:	07882-1037
Country	:	US
Telephone Number	:	908-892-1952
Fax Number	:

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

Provider Enumeration Date	:	03/18/2020
Last Update Date	:	03/18/2020

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