=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699463695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSIDY JOLYNN BAKER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2023
-----------------------------------------------------
Last Update Date | 04/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 VICTORY PKWY
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45207-1035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-745-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1725 CLENEAY AVE APT 1139
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45212-3591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-892-6089
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------