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General NPI Number Information
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NPI Number | 1881730018
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Entity Type | Individual
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Provider Name | LAMOYNE HAWLEY AT,C
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Gender | Male
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 06/01/2023
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Provider Practice Location Address
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Address Line | 10320 75TH ST
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City | KENOSHA
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State | WI
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Zip | 53142-7525
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Country | US
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Telephone | 262-697-6143
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Fax |
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Provider Business Mailing Address
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Address Line | 9984 50TH AVE
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City | PLEASANT PRAIRIE
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State | WI
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Zip | 53158-6530
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Country | US
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Telephone | 262-308-6968
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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 | 12-039
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License Number State | WI
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