Healthcare Provider Details

I. General information

NPI: 1336101310
Provider Name (Legal Business Name): TANYA MARIE MAXWELL A.T.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 PEACHTREE RD NE 700
ATLANTA GA
30309-1414
US

IV. Provider business mailing address

2045 PEACHTREE RD NE
ATLANTA GA
30309-1414
US

V. Phone/Fax

Practice location:
  • Phone: 404-350-3540
  • Fax: 404-605-0371
Mailing address:
  • Phone: 678-732-1336
  • Fax: 404-605-0371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001062
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: