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General NPI Number Information
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NPI Number | 1619485273
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Entity Type | Individual
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Provider Name | MARISSA LYNN HAUG LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 01/17/2018
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Last Update Date | 01/17/2018
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Provider Practice Location Address
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Address Line | N4021 COUNTY RD E
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City | FREEDOM
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State | WI
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Zip | 54130-7593
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Country | US
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Telephone | 920-788-7940
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Fax |
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Provider Business Mailing Address
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Address Line | 2803 S WHEATFIELD DR
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City | APPLETON
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State | WI
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Zip | 54915-2168
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Country | US
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Telephone | 920-629-9831
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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 | 2000011062
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License Number State | WI
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