Healthcare Provider Details

I. General information

NPI: 1134695968
Provider Name (Legal Business Name): GABRIELLE ROSE HOFMEISTER LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY RD
PEMBROKE NC
28372-8699
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 910-775-4106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4957
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: