MEDICARE: MS. ALEENA KANNER 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	2000025464	NY

General Provider Information

NPI Number	:	1306584651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALEENA KANNER ATC

Provider Business Mailing Address
First Line	:	432 SAMUELS AVE APT 3408
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-2488
Country	:	US
Telephone Number	:	516-388-1010
Fax Number	:

Provider Business Practice Location Address
First Line	:	432 SAMUELS AVE APT 3408
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-2488
Country	:	US
Telephone Number	:	516-388-1010
Fax Number	:

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

Provider Enumeration Date	:	05/26/2022
Last Update Date	:	05/26/2022

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