Healthcare Provider Details

I. General information

NPI: 1992246128
Provider Name (Legal Business Name): ISABELA COLLINS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 ORANGE ST
SAINT AUGUSTINE FL
32084-3633
US

IV. Provider business mailing address

13 E ST APT B
ST AUGUSTINE FL
32080-4756
US

V. Phone/Fax

Practice location:
  • Phone: 904-547-8660
  • Fax:
Mailing address:
  • Phone: 772-233-1548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL4935
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: