Healthcare Provider Details

I. General information

NPI: 1205498037
Provider Name (Legal Business Name): KAITLYN LAZICKY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 ALLEN DR
BETHLEHEM PA
18017-8223
US

IV. Provider business mailing address

5005 ALLEN DR
BETHLEHEM PA
18017-8223
US

V. Phone/Fax

Practice location:
  • Phone: 610-837-8507
  • Fax:
Mailing address:
  • Phone: 484-892-1417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: