Healthcare Provider Details

I. General information

NPI: 1619941572
Provider Name (Legal Business Name): JULIE WILLMERT ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E NORTH H ST
GAS CITY IN
46933-1147
US

IV. Provider business mailing address

242 SHERMAN ST
WABASH IN
46992-1112
US

V. Phone/Fax

Practice location:
  • Phone: 765-674-2248
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001161A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: