Healthcare Provider Details

I. General information

NPI: 1073172821
Provider Name (Legal Business Name): ROSALIE MARIE FIDANZE LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 LAKEVIEW DR
NOBLESVILLE IN
46060-1210
US

IV. Provider business mailing address

5744 EVANSTON AVE
INDIANAPOLIS IN
46220-2808
US

V. Phone/Fax

Practice location:
  • Phone: 317-776-1061
  • Fax:
Mailing address:
  • Phone: 630-536-7949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003480A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: