Healthcare Provider Details

I. General information

NPI: 1093389827
Provider Name (Legal Business Name): ANNIKA KEZMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 GLEN RD
VIRGINIA BEACH VA
23452-2602
US

IV. Provider business mailing address

4024 GLEN RD
VIRGINIA BEACH VA
23452-2602
US

V. Phone/Fax

Practice location:
  • Phone: 757-537-5114
  • Fax:
Mailing address:
  • Phone:
  • 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: