Healthcare Provider Details

I. General information

NPI: 1902819436
Provider Name (Legal Business Name): LORA SERAPHIN FITZGERALD MA, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 W ROSEDALE ST STE. 200
FT WORTH TX
76104-7437
US

IV. Provider business mailing address

5524 LA BANDERA TRL
BENBROOK TX
76126-1843
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-4316
  • Fax: 817-336-2504
Mailing address:
  • Phone: 337-212-3849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: