MEDICARE: MRS. ANGELA MARIE FRADY ATC, OTC

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	1022	NC

General Provider Information

NPI Number	:	1982968616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGELA MARIE FRADY ATC, OTC

Provider Business Mailing Address
First Line	:	1130 BEACHVIEW STREET
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75218
Country	:	US
Telephone Number	:	469-341-5576
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 BEACHVIEW ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75218-3700
Country	:	US
Telephone Number	:	469-341-5676
Fax Number	:

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

Provider Enumeration Date	:	06/27/2012
Last Update Date	:	11/08/2013

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