Healthcare Provider Details

I. General information

NPI: 1326248402
Provider Name (Legal Business Name): AMBER ROSE SUCKOW ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 NEWELL AVE
FREDERICKSBURG IA
50630-9515
US

IV. Provider business mailing address

2865 NEWELL AVE
FREDERICKSBURG IA
50630-9515
US

V. Phone/Fax

Practice location:
  • Phone: 480-751-8368
  • Fax:
Mailing address:
  • Phone: 480-751-8368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0711
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: