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General NPI Number Information
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NPI Number | 1952450694
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Entity Type | Individual
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Provider Name | TIFFANY LYN FONAGY A.T.C., P.E.S.
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Gender | Female
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 75 EVELYN DR
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City | MILLERSBURG
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State | PA
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Zip | 17061-1258
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Country | US
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Telephone | 717-692-4708
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Fax | 717-692-5464
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Provider Business Mailing Address
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Address Line | 4175 MOUNTAIN VIEW RD APT 109
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City | MECHANICSBURG
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State | PA
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Zip | 17050-7628
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Country | US
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Telephone | 717-732-1819
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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 | RTO000015
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License Number State | PA
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