Healthcare Provider Details

I. General information

NPI: 1184900250
Provider Name (Legal Business Name): STACY LYNN OGDEN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 UNIVERSITY BLVD
MOON TOWNSHIP PA
15108-2574
US

IV. Provider business mailing address

6001 UNIVERSITY BLVD
MOON TOWNSHIP PA
15108-2574
US

V. Phone/Fax

Practice location:
  • Phone: 412-397-4981
  • Fax: 412-397-4992
Mailing address:
  • Phone: 412-397-4981
  • Fax: 412-397-4992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004523
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: