Healthcare Provider Details

I. General information

NPI: 1528131752
Provider Name (Legal Business Name): LAURA LEE FAFARA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11134 N STATE ROAD 77
HAYWARD WI
54843-5325
US

IV. Provider business mailing address

16223 W EASY ST
HAYWARD WI
54843-2586
US

V. Phone/Fax

Practice location:
  • Phone: 715-634-5505
  • Fax: 715-634-5558
Mailing address:
  • Phone: 715-634-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number396-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: