Healthcare Provider Details

I. General information

NPI: 1376579847
Provider Name (Legal Business Name): KIERNAN ELIZABETH MELOGRANA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 GRANDVIEW BLVD
WEST LAWN PA
19609-1324
US

IV. Provider business mailing address

2101 BURKEY DR
WYOMISSING PA
19610-1546
US

V. Phone/Fax

Practice location:
  • Phone: 610-670-0185
  • Fax:
Mailing address:
  • Phone: 610-678-3056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT002414A
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: