MEDICARE: LISA ELLEN GREENFIELD 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	AL4280	FL

General Provider Information

NPI Number	:	1619545837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ELLEN GREENFIELD LAT

Provider Business Mailing Address
First Line	:	1787 E GROVEHILL RD
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-3923
Country	:	US
Telephone Number	:	727-614-2019
Fax Number	:

Provider Business Practice Location Address
First Line	:	1787 E GROVEHILL RD
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-3923
Country	:	US
Telephone Number	:	727-614-2019
Fax Number	:

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

Provider Enumeration Date	:	06/14/2021
Last Update Date	:	06/14/2021

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