MEDICARE: KELLIE HANNO 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	AL3907	FL

General Provider Information

NPI Number	:	1841826054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE HANNO ATC, LAT

Provider Business Mailing Address
First Line	:	1904 19TH WAY
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-6626
Country	:	US
Telephone Number	:	239-313-0453
Fax Number	:

Provider Business Practice Location Address
First Line	:	1904 19TH WAY
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-6626
Country	:	US
Telephone Number	:	239-313-0453
Fax Number	:

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

Provider Enumeration Date	:	03/19/2020
Last Update Date	:	03/19/2020

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