Healthcare Provider Details

I. General information

NPI: 1053676551
Provider Name (Legal Business Name): JESSIE LEE ZUCNICK-KIMBUGWE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MERIDIAN ST
NORMAL AL
35762
US

IV. Provider business mailing address

3806 FORCE DR NW
HUNTSVILLE AL
35810-2302
US

V. Phone/Fax

Practice location:
  • Phone: 256-372-8458
  • Fax: 256-372-8480
Mailing address:
  • Phone: 256-372-8458
  • Fax: 256-372-8480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number914
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: