Healthcare Provider Details

I. General information

NPI: 1821377375
Provider Name (Legal Business Name): LAUREN DIANE BAUMANN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 EGG HARBOR RD., SUITE 108
STURGEON BAY WI
54235-1277
US

IV. Provider business mailing address

1300 EGG HARBOR RD., SUITE 108
STURGEON BAY WI
54235-1277
US

V. Phone/Fax

Practice location:
  • Phone: 920-746-0410
  • Fax: 920-746-0244
Mailing address:
  • Phone: 920-746-0410
  • Fax: 920-746-0244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1261-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: