=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366637209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER LYN-NIEBOER SMITH ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2007
-----------------------------------------------------
Last Update Date | 04/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2140 BAUER RD
-----------------------------------------------------
City | JENISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49428-9539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-457-8454
-----------------------------------------------------
Fax | 616-457-8441
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2140 BAUER RD
-----------------------------------------------------
City | JENISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49428-9539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-457-8454
-----------------------------------------------------
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 | 2601000712
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------