Healthcare Provider Details

I. General information

NPI: 1962875385
Provider Name (Legal Business Name): ALLISON PIERCE LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2015
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 MEMORIAL DR
TWO RIVERS WI
54241-3900
US

IV. Provider business mailing address

5000 MEMORIAL DR
TWO RIVERS WI
54241-3900
US

V. Phone/Fax

Practice location:
  • Phone: 920-794-5000
  • Fax: 920-794-5472
Mailing address:
  • Phone: 920-794-5000
  • Fax: 920-794-5472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1050-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: