Healthcare Provider Details

I. General information

NPI: 1457820532
Provider Name (Legal Business Name): BROOKKE DANNYEL MAHAFFEY LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2018
Last Update Date: 11/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 EVERGREEN DR
LORETTO PA
15940-9704
US

IV. Provider business mailing address

117 EVERGREEN DR
LORETTO PA
15940-9704
US

V. Phone/Fax

Practice location:
  • Phone: 814-472-3275
  • Fax: 814-472-2786
Mailing address:
  • Phone: 814-472-3275
  • Fax: 814-472-2786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT006085
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: