Individual
MIA PROVENZANO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1320 S VAL VISTA DR APT 1066, MESA, AZ 85204-6491
(989) 964-1089
Mailing address
1320 S VAL VISTA DR APT 1066, MESA, AZ 85204-6491
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
—
Other
Enumeration date
07/15/2015
Last updated
07/15/2015
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