Healthcare Provider Details

I. General information

NPI: 1932716784
Provider Name (Legal Business Name): HEIDI BOHL LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

W6826 COUNTY ROAD O
HORTONVILLE WI
54944-9742
US

V. Phone/Fax

Practice location:
  • Phone: 920-991-2561
  • Fax:
Mailing address:
  • Phone: 920-740-8520
  • 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: