=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629754551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATALIE DZIADON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2023
-----------------------------------------------------
Last Update Date | 07/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13662 MOLLY PITCHER HIGHWAY
-----------------------------------------------------
City | GREENCASTLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-991-2137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17423 LEXINGTON AVE
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-302-1267
-----------------------------------------------------
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 | P4TMQKLIO3
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------