Healthcare Provider Details

I. General information

NPI: 1790277234
Provider Name (Legal Business Name): LAURA IVY CAMPBELL LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 WOODBINE LN
DANVILLE PA
17821-8029
US

IV. Provider business mailing address

290 NURSERY RD
BERWICK PA
18603-5128
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6700
  • Fax:
Mailing address:
  • Phone: 570-394-8907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRTO000383
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: