Healthcare Provider Details

I. General information

NPI: 1053604744
Provider Name (Legal Business Name): SARENA HEADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 TRI PARK WAY STE A
APPLETON WI
54914-1698
US

IV. Provider business mailing address

1650 TRI PARK WAY
APPLETON WI
54914-1652
US

V. Phone/Fax

Practice location:
  • Phone: 920-830-6697
  • Fax: 920-830-6707
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: