Provider Demographics
NPI:1790210235
Name:SURACE, BRITTAINY (MED, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BRITTAINY
Middle Name:
Last Name:SURACE
Suffix:
Gender:F
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:KS
Mailing Address - Zip Code:67579-2117
Mailing Address - Country:US
Mailing Address - Phone:216-854-0069
Mailing Address - Fax:
Practice Address - Street 1:125 W COOPER ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:KS
Practice Address - Zip Code:67579-1533
Practice Address - Country:US
Practice Address - Phone:620-278-4259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-010662255A2300X
OHAT0039582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer