Healthcare Provider Details

I. General information

NPI: 1023673878
Provider Name (Legal Business Name): COURTNEY LYNN WAGNER LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 10/13/2024
Certification Date: 10/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E ENTERPRISE AVE # 113
APPLETON WI
54913-7862
US

IV. Provider business mailing address

N7898 LAKESHORE DR
FOND DU LAC WI
54937-1647
US

V. Phone/Fax

Practice location:
  • Phone: 920-991-2561
  • Fax:
Mailing address:
  • Phone: 920-517-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1890-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: