MEDICARE: CASSANDRA TIMMERS 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		WI

General Provider Information

NPI Number	:	1700448933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSANDRA TIMMERS LAT

Provider Business Mailing Address
First Line	:	2105 E ENTERPRISE AVE
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54913-7862
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 NORTH BALLARD ROAD
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54913-5491
Country	:	US
Telephone Number	:	920-832-4300
Fax Number	:

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

Provider Enumeration Date	:	07/09/2019
Last Update Date	:	07/09/2019

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