MEDICARE: JULIE WILLMERT 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	36001161A	IN

General Provider Information

NPI Number	:	1619941572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE WILLMERT ATC, LAT

Provider Business Mailing Address
First Line	:	242 SHERMAN ST
Second Line	:
City	:	WABASH
State	:	IN
Zip	:	46992-1112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 E NORTH H ST
Second Line	:
City	:	GAS CITY
State	:	IN
Zip	:	46933-1147
Country	:	US
Telephone Number	:	765-674-2248
Fax Number	:

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

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	07/08/2007

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