=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568965994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA AMANDA DONALDSON ATC, MBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2018
-----------------------------------------------------
Last Update Date | 03/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2701 FAIRVIEW RD
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-5563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-559-0231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9304 W PLAINFIELD AVE
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53228-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-388-1918
-----------------------------------------------------
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 | 2000017880
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------