=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275878852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEIDI NEITZKE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2012
-----------------------------------------------------
Last Update Date | 12/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 NEWBURG RD KNIGHTS HALL
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40205-1863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-272-8379
-----------------------------------------------------
Fax | 502-272-7341
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 NEWBURG RD KNIGHTS HALL
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40205-1863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-272-8379
-----------------------------------------------------
Fax | 502-272-7341
-----------------------------------------------------
=====================================================
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 | AT841
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------