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General NPI Number Information
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NPI Number | 1245655398
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Entity Type | Individual
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Provider Name | BETHANY GRACE DRUVENGA LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 02/26/2014
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Last Update Date | 08/19/2022
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Provider Practice Location Address
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Address Line | 1301 COLLEGE AVE # 103
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City | FREDERICKSBURG
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State | VA
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Zip | 22401-5300
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Country | US
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Telephone | 540-654-1874
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Fax |
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Provider Business Mailing Address
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Address Line | 1603 HUDGINS FARM CIR
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City | FREDERICKSBURG
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State | VA
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Zip | 22408-4191
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Country | US
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Telephone | 712-260-0671
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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 | 0126001802
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License Number State | VA
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