Healthcare Provider Details

I. General information

NPI: 1043236409
Provider Name (Legal Business Name): MARCHELL MARIE CUPPETT ATC, EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12901 BRUCE B DOWNS BLVD MDC54
TAMPA FL
33612-4742
US

IV. Provider business mailing address

15210 AMBERLY DR APT 2125
TAMPA FL
33647-2196
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-7831
  • Fax:
Mailing address:
  • Phone: 813-974-7831
  • Fax: 813-974-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 1479
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: