Healthcare Provider Details

I. General information

NPI: 1770026353
Provider Name (Legal Business Name): STEPHANIE DANA FLETCHER LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 08/05/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVIANO AIR BASE AREA F BLDG 1466
APO AE
09603
US

IV. Provider business mailing address

PSC 103 BOX 179
APO AE
09603-0002
US

V. Phone/Fax

Practice location:
  • Phone: 856-364-8796
  • Fax:
Mailing address:
  • Phone: 856-364-8796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT007576
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: