Provider Demographics
NPI:1598201840
Name:VANOVER, ERICA LEIGH (LAT, ATC)
Entity Type:Individual
Prefix:MISS
First Name:ERICA
Middle Name:LEIGH
Last Name:VANOVER
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8441 TIBBERMORE CT
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-9721
Mailing Address - Country:US
Mailing Address - Phone:614-288-3612
Mailing Address - Fax:
Practice Address - Street 1:727 W RAAB RD APT 11
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-4145
Practice Address - Country:US
Practice Address - Phone:614-288-3612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 2255A2300X
IL096.0049552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program