Healthcare Provider Details

I. General information

NPI: 1891203063
Provider Name (Legal Business Name): ALEXANDRA MJOLL GUDBERGSDOTTIR ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 PHARR RD NE
ATLANTA GA
30305-3200
US

IV. Provider business mailing address

2158 CUMBERLAND PKWY SE APT 13408
ATLANTA GA
30339-4589
US

V. Phone/Fax

Practice location:
  • Phone: 404-231-1872
  • Fax: 404-231-3346
Mailing address:
  • Phone: 678-862-3658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000029959
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: