Healthcare Provider Details

I. General information

NPI: 1295297604
Provider Name (Legal Business Name): CHELSEA N ECTOR ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 BULLDOG CIR NE
CONYERS GA
30012-4708
US

IV. Provider business mailing address

3764 CONLEY DOWNS DR
DECATUR GA
30034-6986
US

V. Phone/Fax

Practice location:
  • Phone: 770-483-4713
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003290
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: