Healthcare Provider Details

I. General information

NPI: 1215483540
Provider Name (Legal Business Name): NICOLE EMILIA RENFROE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 RONALD REAGAN BLVD STE 300
CUMMING GA
30041-6290
US

IV. Provider business mailing address

2860 RONALD REAGAN BLVD
CUMMING GA
30041-6287
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-0743
  • Fax: 404-425-1609
Mailing address:
  • Phone: 404-355-0743
  • Fax: 404-425-1609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003585
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: