=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104679216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANNAH COLLINS FRAIN LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2024
-----------------------------------------------------
Last Update Date | 04/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 TOWER PKWY
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-432-1444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1659 COUNTRY WALK DR
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-8614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-656-9585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1701
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------