Healthcare Provider Details

I. General information

NPI: 1225255797
Provider Name (Legal Business Name): SHANICK TAMARA AUGUSTIN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8945 W COLONIAL DR
OCOEE FL
34761-6918
US

IV. Provider business mailing address

7220 WESTPOINTE BLVD #1426
ORLANDO FL
32835-6126
US

V. Phone/Fax

Practice location:
  • Phone: 407-822-7506
  • Fax:
Mailing address:
  • Phone: 407-496-5152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL2296
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: