Healthcare Provider Details

I. General information

NPI: 1942812128
Provider Name (Legal Business Name): SAMANTHA NORMAN KHEBOIAN LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA KATE NORMAN LAT, ATC

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 LAKESHORE AVE
BEVERLY MA
01915-1907
US

IV. Provider business mailing address

71 LAKESHORE AVE
BEVERLY MA
01915-1907
US

V. Phone/Fax

Practice location:
  • Phone: 781-760-2769
  • Fax:
Mailing address:
  • Phone: 781-760-2769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2533
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: