MEDICARE: LAUREN ANNICK PETTYJOHN-ROBIN

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
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2255A2300X	Athletic Trainer	003962	NY

General Provider Information

NPI Number	:	1144701970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN ANNICK PETTYJOHN-ROBIN

Provider Business Mailing Address
First Line	:	6404 ORLY LN
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20707-2980
Country	:	US
Telephone Number	:	301-875-7154
Fax Number	:

Provider Business Practice Location Address
First Line	:	6404 ORLY LN
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20707-2980
Country	:	US
Telephone Number	:	301-875-7154
Fax Number	:

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

Provider Enumeration Date	:	08/29/2018
Last Update Date	:	03/15/2023

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