=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972042422
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDY VINSON A.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2017
-----------------------------------------------------
Last Update Date | 02/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1198 SMILEY AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45240-1865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-671-6362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3624 TAMARACK AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45207-1317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-321-3606
-----------------------------------------------------
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 | 002653
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------