Healthcare Provider Details

I. General information

NPI: 1083749550
Provider Name (Legal Business Name): MARCIE BETH FYOCK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WOOD ST
CLARION PA
16214-1240
US

IV. Provider business mailing address

13 E 8TH AVE
CLARION PA
16214-1601
US

V. Phone/Fax

Practice location:
  • Phone: 814-393-2006
  • Fax: 814-393-1735
Mailing address:
  • Phone: 814-393-2006
  • Fax: 814-393-1735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT003067
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: