Healthcare Provider Details

I. General information

NPI: 1790210672
Provider Name (Legal Business Name): EMMA FISH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HULL RD
GAINESVILLE FL
32607-4144
US

IV. Provider business mailing address

3406 N MOUNTAIN VIEW DR
SAN DIEGO CA
92116-1947
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7001
  • Fax:
Mailing address:
  • Phone: 619-730-8287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: