MEDICARE: BRENNA M ALLEN 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	A0001431	MD

General Provider Information

NPI Number	:	1699485441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENNA M ALLEN ATC, LAT

Provider Business Mailing Address
First Line	:	8637 SHADY PINES DR
Second Line	:
City	:	URBANA
State	:	MD
Zip	:	21704-6765
Country	:	US
Telephone Number	:	919-995-1469
Fax Number	:

Provider Business Practice Location Address
First Line	:	8637 SHADY PINES DR
Second Line	:
City	:	URBANA
State	:	MD
Zip	:	21704-6765
Country	:	US
Telephone Number	:	919-995-1469
Fax Number	:

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

Provider Enumeration Date	:	12/02/2022
Last Update Date	:	12/02/2022

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