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NPI Code Detail

MEDICARE: MISS SHANNON LEAH HATTERVIG ATC

MEDICARE: MISS SHANNON LEAH HATTERVIG 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
12255A2300XAthletic TrainerAT-1004CO

General Provider Information

NPI Number : 1740551456
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS SHANNON LEAH HATTERVIG ATC
Provider Business Mailing Address
First Line : 552 GUNNISON AVE APT 3
Second Line :
City : GRAND JUNCTION
State : CO
Zip : 81501-4801
Country : US
Telephone Number : 605-391-6713
Fax Number :
Provider Business Practice Location Address
First Line : 1100 NORTH AVE
Second Line :
City : GRAND JUNCTION
State : CO
Zip : 81501-3122
Country : US
Telephone Number : 970-248-1985
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/26/2012
Last Update Date : 05/01/2014

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Directions to “ MISS SHANNON LEAH HATTERVIG ATC” Practice Location

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