Healthcare Provider Details

I. General information

NPI: 1407595309
Provider Name (Legal Business Name): NINA LYNN COLETTA ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13837 CIRCA CROSSING DR
LITHIA FL
33547-4382
US

IV. Provider business mailing address

19628 45TH AVE
FLUSHING NY
11358-3508
US

V. Phone/Fax

Practice location:
  • Phone: 813-684-2663
  • Fax:
Mailing address:
  • Phone: 718-791-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: