MEDICARE: ELLEN MYREE HICKS ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	0126000363	VA

General Provider Information

NPI Number	:	1003203431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN MYREE HICKS ATC

Provider Business Mailing Address
First Line	:	5939 FLANK CIR
Second Line	:
City	:	PORT REPUBLIC
State	:	VA
Zip	:	24471-2231
Country	:	US
Telephone Number	:	540-828-5368
Fax Number	:	540-515-3763

Provider Business Practice Location Address
First Line	:	5939 FLANK CIR
Second Line	:
City	:	PORT REPUBLIC
State	:	VA
Zip	:	24471-2231
Country	:	US
Telephone Number	:	540-828-5368
Fax Number	:	540-515-3763

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	04/23/2015

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