Healthcare Provider Details

I. General information

NPI: 1871252601
Provider Name (Legal Business Name): CARLEE ANN CONRAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 COUNTY ROAD 45
AUBURN IN
46706-9773
US

IV. Provider business mailing address

4055 COUNTY ROAD 45
AUBURN IN
46706-9773
US

V. Phone/Fax

Practice location:
  • Phone: 260-570-8533
  • Fax:
Mailing address:
  • Phone: 260-570-8533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: