MEDICARE: MS. AMY JOHANNA VANNEDERPELT ATC, LAT

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		MA

General Provider Information

NPI Number	:	1356486849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMY JOHANNA VANNEDERPELT ATC, LAT

Provider Business Mailing Address
First Line	:	218 SCHOOL ST
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02451-4551
Country	:	US
Telephone Number	:	781-492-7669
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 UNIVERSITY AVE
Second Line	:
City	:	LOWELL
State	:	MA
Zip	:	01854-2827
Country	:	US
Telephone Number	:	978-934-2310
Fax Number	:

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

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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