Healthcare Provider Details

I. General information

NPI: 1619432614
Provider Name (Legal Business Name): LAUREN WHETZEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 CAMDEN AVE
SALISBURY MD
21801-6837
US

IV. Provider business mailing address

6407 WOODSIDE VIEW DR
DUNKIRK MD
20754-2509
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-6000
  • Fax:
Mailing address:
  • Phone: 240-427-7715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: