=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619397973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA STEFFEN LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2014
-----------------------------------------------------
Last Update Date | 04/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12800 N LAKE SHORE DR
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53097-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-243-4537
-----------------------------------------------------
Fax | 262-243-2969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12800 N LAKE SHORE DR
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53097-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-243-4537
-----------------------------------------------------
Fax | 262-243-2969
-----------------------------------------------------
=====================================================
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 | 978-39
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------