Healthcare Provider Details

I. General information

NPI: 1285276220
Provider Name (Legal Business Name): BROOKE FADNESS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SHELTER DR
SOUND BEACH NY
11789-2124
US

IV. Provider business mailing address

4 SHELTER DR
SOUND BEACH NY
11789-2124
US

V. Phone/Fax

Practice location:
  • Phone: 631-384-2871
  • Fax:
Mailing address:
  • Phone: 631-384-2871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001851-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: