Healthcare Provider Details

I. General information

NPI: 1700448933
Provider Name (Legal Business Name): CASSANDRA TIMMERS LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 NORTH BALLARD ROAD
APPLETON WI
54913-5491
US

IV. Provider business mailing address

2105 E ENTERPRISE AVE
APPLETON WI
54913-7862
US

V. Phone/Fax

Practice location:
  • Phone: 920-832-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: