MEDICARE: ANANDA LAYNE MAT, LAT, 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	7627	FL

General Provider Information

NPI Number	:	1407601610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANANDA LAYNE MAT, LAT, ATC

Provider Business Mailing Address
First Line	:	5221 MILLENIA BLVD APT 304
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839-6135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 S RIO GRANDE AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32805-3799
Country	:	US
Telephone Number	:	407-835-2300
Fax Number	:

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

Provider Enumeration Date	:	04/22/2024
Last Update Date	:	01/21/2026

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