Healthcare Provider Details

I. General information

NPI: 1871528588
Provider Name (Legal Business Name): LISA M YEAGLEY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1267 BEALL AVE. THE COLLEGE OF WOOSTER
WOOSTER OH
44691
US

IV. Provider business mailing address

1557 LEMAR DR
WOOSTER OH
44691-2541
US

V. Phone/Fax

Practice location:
  • Phone: 330-263-2190
  • Fax:
Mailing address:
  • Phone: 330-714-4188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 002065
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: