=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932551199
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYRENA DAWN SPANBURGH-HESS LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2016
-----------------------------------------------------
Last Update Date | 07/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1162 EDEN TER
-----------------------------------------------------
City | ROCK HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29730-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-323-2129
-----------------------------------------------------
Fax | 803-323-3933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 OAKWOOD DR
-----------------------------------------------------
City | WHITEHALL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18052-7216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-547-4161
-----------------------------------------------------
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 | 1770
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | RT006156
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------