Basic Information
| Provider Information | |||||||||
| NPI: | 1700088697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLEENER | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 634 GREENE ST | ||||||||
| Address2: | |||||||||
| City: | SLATER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502449703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154801874 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1215 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152394475 | ||||||||
| FaxNumber: | 5152394722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2007 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 00106 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363AM0700X | 074631 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 22 | 01 | IA | CERTIFIED ATHLETIC TRAINE | OTHER |