Healthcare Provider Details

I. General information

NPI: 1053643916
Provider Name (Legal Business Name): MELISSA PEARL LONGNECKER MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 WOODBINE LN
DANVILLE PA
17821-9118
US

IV. Provider business mailing address

717 ASH ST
WATSONTOWN PA
17777-1104
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-5555
  • Fax:
Mailing address:
  • Phone: 814-573-2585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004350
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: