Healthcare Provider Details

I. General information

NPI: 1215608815
Provider Name (Legal Business Name): AVERY NICOLE MANBECK MS, LAT, ATC, OTC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 10/11/2026
Certification Date: 10/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 PEACHTREE RD NE STE 705
ATLANTA GA
30309-1476
US

IV. Provider business mailing address

5070 PEACHTREE BLVD UNIT 1128
CHAMBLEE GA
30341-2880
US

V. Phone/Fax

Practice location:
  • Phone: 571-442-0320
  • Fax:
Mailing address:
  • Phone: 571-442-0320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: