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General NPI Number Information
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NPI Number | 1225542129
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Entity Type | Individual
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Provider Name | STACI LYNN BOHANNON ATC
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Gender | Female
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Dates
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Enumeration Date | 11/30/2017
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Last Update Date | 11/30/2017
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Provider Practice Location Address
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Address Line | 8585 OH-14
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City | STREETSBORO
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State | OH
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Zip | 44241
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Country | US
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Telephone | 440-212-1383
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Fax |
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Provider Business Mailing Address
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Address Line | 638 TAMPICO CT
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City | BEREA
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State | OH
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Zip | 44017-2636
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Country | US
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Telephone | 440-212-1383
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT.004892
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License Number State | OH
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