Healthcare Provider Details

I. General information

NPI: 1013432467
Provider Name (Legal Business Name): ALEXANDRIA ROSWITA SAWYER LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N JOHN R WOODEN DR
WEST LAFAYETTE IN
47907-2117
US

IV. Provider business mailing address

10525 S LONGWOOD DR
CHICAGO IL
60643-2615
US

V. Phone/Fax

Practice location:
  • Phone: 765-494-1703
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003587
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: