Healthcare Provider Details

I. General information

NPI: 1467065441
Provider Name (Legal Business Name): AJA NICOLE BENN LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 HAWKS LN NE STE 200
BROOKHAVEN GA
30329-2283
US

IV. Provider business mailing address

1003 EASTWOOD VILLAGE DR
STOCKBRIDGE GA
30281-7752
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3350
  • Fax:
Mailing address:
  • Phone: 470-219-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001613
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: