Provider Demographics
NPI:1649798067
Name:VANIC, KEITH ANTHONY (PHD, ATC, LAT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ANTHONY
Last Name:VANIC
Suffix:
Gender:M
Credentials:PHD, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5992 KESSLERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-9374
Mailing Address - Country:US
Mailing Address - Phone:484-357-3396
Mailing Address - Fax:570-422-3616
Practice Address - Street 1:5992 KESSLERSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:NAZARETH
Practice Address - State:PA
Practice Address - Zip Code:18064
Practice Address - Country:US
Practice Address - Phone:484-357-3396
Practice Address - Fax:570-422-3616
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART001357A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer