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General NPI Number Information
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NPI Number | 1427886415
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Entity Type | Individual
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Provider Name | RAEGAN WILLIS ATC
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Gender | Female
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Dates
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Enumeration Date | 07/23/2024
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Last Update Date | 07/23/2024
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Provider Practice Location Address
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Address Line | 906 E 1ST ST
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City | THIBODAUX
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State | LA
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Zip | 70301-6701
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Country | US
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Telephone | 985-448-4507
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Fax |
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Provider Business Mailing Address
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Address Line | 16923 EVERGREEN HILLS AVE
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City | GREENWELL SPRINGS
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State | LA
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Zip | 70739-3920
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Country | US
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Telephone |
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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 | 334488
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License Number State | LA
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