Healthcare Provider Details

I. General information

NPI: 1275840639
Provider Name (Legal Business Name): AMY C MUSSELMAN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 01/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 PEACHTREE RD NE
ATLANTA GA
30309-1414
US

IV. Provider business mailing address

11024 PERIMETER TRCE E
ATLANTA GA
30346-1931
US

V. Phone/Fax

Practice location:
  • Phone: 678-732-1332
  • Fax: 404-425-1622
Mailing address:
  • Phone: 678-732-1332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number11-1114
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001793
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: