=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679987325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANITA LYNNE GROOVER-SMITH LAT/ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2014
-----------------------------------------------------
Last Update Date | 06/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3931 WILLIAM PENN HIGHWAY JUNIATA HIGH SCHOOL
-----------------------------------------------------
City | MIFFLINTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-436-2193
-----------------------------------------------------
Fax | 717-436-2858
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3931 WILLIAM PENN HIGHWAY JUNIATA HIGH SCHOOL
-----------------------------------------------------
City | MIFFLINTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-436-2193
-----------------------------------------------------
Fax | 717-436-2858
-----------------------------------------------------
=====================================================
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 | RT001192A
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------