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General NPI Number Information
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NPI Number | 1265039622
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Entity Type | Individual
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Provider Name | JESSICA VERONICA FITTIPALDI LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 10/07/2020
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Last Update Date | 10/07/2020
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Provider Practice Location Address
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Address Line | 170 PAULISON AVE
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City | PASSAIC
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State | NJ
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Zip | 07055-4810
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Country | US
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Telephone | 862-377-5427
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Fax |
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Provider Business Mailing Address
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Address Line | 255 W HIGH ST
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City | BOUND BROOK
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State | NJ
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Zip | 08805-1658
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Country | US
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Telephone | 732-447-8851
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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 | 25MT00216100
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License Number State | NJ
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