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General NPI Number Information
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NPI Number | 1316426745
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Entity Type | Individual
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Provider Name | SHAYLA ALYSON VANGURP ATC
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Gender | Female
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Dates
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Enumeration Date | 08/07/2018
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Last Update Date | 08/07/2018
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Provider Practice Location Address
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Address Line | 630 MORICHES MIDDLE ISLAND RD
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City | MORICHES
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State | NY
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Zip | 11955-1506
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Country | US
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Telephone | 631-874-5505
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Fax |
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Provider Business Mailing Address
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Address Line | 100 RAYNOR RD
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City | RIDGE
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State | NY
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Zip | 11961-1900
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Country | US
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Telephone | 631-258-2384
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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 | 2000033529
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License Number State | NY
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