MEDICARE: MRS. HALEY KIRSTEN LANTIEGNE MA, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2000007879	CA

General Provider Information

NPI Number	:	1043094923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HALEY KIRSTEN LANTIEGNE MA, ATC

Provider Business Mailing Address
First Line	:	1955 YUCCA DR
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92882-5617
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 SUPERIOR AVE STE 200
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-3659
Country	:	US
Telephone Number	:	949-763-7133
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2023
Last Update Date	:	08/22/2023

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