Healthcare Provider Details

I. General information

NPI: 1417341553
Provider Name (Legal Business Name): KRISTINA MERRITT LAZICKI ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HILLTOP CIR RAC 221
BALTIMORE MD
21250-0001
US

IV. Provider business mailing address

1000 HILLTOP CIR RAC 221
BALTIMORE MD
21250-0001
US

V. Phone/Fax

Practice location:
  • Phone: 410-455-3921
  • Fax: 410-455-1191
Mailing address:
  • Phone: 410-455-3921
  • Fax: 410-455-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA00634
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: