=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295928695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN MARIE-TITHOF PETTY A.T.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2007
-----------------------------------------------------
Last Update Date | 08/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 E GRAND RIVER RD
-----------------------------------------------------
City | WEBBERVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48892-8602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-521-3447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 722 PINEGATE DR
-----------------------------------------------------
City | FOWLERVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48836-8972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-304-4693
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------