=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952484669
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY LYN LEBENGOOD MS, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MOORE AVENUE BUCKNELL UNIVERSITY - KLARC
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-577-3049
-----------------------------------------------------
Fax | 570-577-1660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 N 4TH ST
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-523-0890
-----------------------------------------------------
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 | RT002024A
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------