Healthcare Provider Details

I. General information

NPI: 1184017204
Provider Name (Legal Business Name): MEGHAN GLYNN ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3195 KNIGHT WAY SE
GRAND RAPIDS MI
49546-4409
US

IV. Provider business mailing address

995 TANAGER CT
ANTIOCH IL
60002-6408
US

V. Phone/Fax

Practice location:
  • Phone: 616-526-7674
  • Fax:
Mailing address:
  • Phone: 614-593-2355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: