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General NPI Number Information
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NPI Number | 1548644776
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Entity Type | Individual
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Provider Name | BRANDI PETERS LAT
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Gender | Female
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Dates
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Enumeration Date | 07/17/2015
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Last Update Date | 07/17/2015
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Provider Practice Location Address
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Address Line | 2717 18TH ST SUITE 100
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City | KENOSHA
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State | WI
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Zip | 53140-4666
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Country | US
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Telephone | 262-551-5650
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Fax | 866-245-8064
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Provider Business Mailing Address
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Address Line | PO BOX 3497
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City | STURTEVANT
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State | WI
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Zip | 53177-0300
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Country | US
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Telephone | 877-552-2996
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Fax | 866-245-8064
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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 | 1650-39
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License Number State | WI
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