=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528545670
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER KRISTIN BROWN AT, LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2018
-----------------------------------------------------
Last Update Date | 07/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 HIGH SCHOOL RD
-----------------------------------------------------
City | THE PLAINS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45780-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-797-4521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 E STATE ST APT 303
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45701-1763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-548-8223
-----------------------------------------------------
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 | 10231442-4810
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT005678
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------