Provider Demographics
NPI:1053384735
Name:SCHUCKMAN, BRYNN ELISSA (LAT, ATC)
Entity type:Individual
Prefix:MS
First Name:BRYNN
Middle Name:ELISSA
Last Name:SCHUCKMAN
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 1:806 WOODBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-2781
Mailing Address - Country:US
Mailing Address - Phone:501-908-1050
Mailing Address - Fax:
Practice Address - Street 1:107 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7000
Practice Address - Country:US
Practice Address - Phone:812-855-4509
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001216A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36001216AOtherLICENSED ATHLETIC TRAINER