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General NPI Number Information
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NPI Number | 1740889724
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Entity Type | Individual
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Provider Name | CHRISTINE MARIE PRUISMANN ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 10/21/2020
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Last Update Date | 11/23/2020
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Provider Practice Location Address
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Address Line | 301 N ANKENY BLVD
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City | ANKENY
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State | IA
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Zip | 50023-1730
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Country | US
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Telephone | 850-866-5528
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Fax |
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Provider Business Mailing Address
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Address Line | 102 DESTINY DR
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City | BOONE
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State | IA
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Zip | 50036-1211
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Country | US
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Telephone |
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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 | 098179
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License Number State | IA
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