Healthcare Provider Details

I. General information

NPI: 1386284495
Provider Name (Legal Business Name): ELLYNN JOANN ROLETT LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 INDUSTRIAL PARK ST
GORDO AL
35466-2068
US

IV. Provider business mailing address

800 ENERGY CENTER BLVD APT 3414
NORTHPORT AL
35473-2736
US

V. Phone/Fax

Practice location:
  • Phone: 205-364-1003
  • Fax:
Mailing address:
  • Phone: 309-264-5787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2163
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: