MEDICARE: MISS HEATHER ANN DENNISON 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	25MT00162300	NJ

General Provider Information

NPI Number	:	1174831572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS HEATHER ANN DENNISON ATC

Provider Business Mailing Address
First Line	:	91 BROOKSIDE AVE
Second Line	:	3B
City	:	SOMERVILLE
State	:	NJ
Zip	:	08876-5619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 JACKSON VALLEY RD
Second Line	:
City	:	WASHINGTON
State	:	NJ
Zip	:	07882-1037
Country	:	US
Telephone Number	:	908-689-3050
Fax Number	:

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

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	09/20/2010

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