Healthcare Provider Details

I. General information

NPI: 1902397169
Provider Name (Legal Business Name): LAURIE ANN BIRACREE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 WAKEFIELD ST
ROCHESTER NH
03867-1303
US

IV. Provider business mailing address

13 HEMLOCK ST
ROCHESTER NH
03867-5038
US

V. Phone/Fax

Practice location:
  • Phone: 603-833-0495
  • Fax:
Mailing address:
  • Phone: 603-833-0495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: