MEDICARE: CONNIE W WELLS ATC, LAT, LMBT

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	146N00000X	Basic Emergency Medical Technician	CERTIFICATION	NC
2	2255A2300X	Athletic Trainer	0580	NC
3	225700000X	Massage Therapist	724	NC

General Provider Information

NPI Number	:	1639101496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE W WELLS ATC, LAT, LMBT

Provider Business Mailing Address
First Line	:	599 GARNER CHAPEL RD
Second Line	:
City	:	MOUNT OLIVE
State	:	NC
Zip	:	28365-6146
Country	:	US
Telephone Number	:	919-658-0476
Fax Number	:

Provider Business Practice Location Address
First Line	:	599 GARNER CHAPEL RD
Second Line	:
City	:	MOUNT OLIVE
State	:	NC
Zip	:	28365-6146
Country	:	US
Telephone Number	:	919-658-0476
Fax Number	:

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	09/11/2025

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