Healthcare Provider Details

I. General information

NPI: 1356974380
Provider Name (Legal Business Name): SHEILAH ISIOMA ESUZOR-AVILEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 GREENBELT DR
GRIFFIN GA
30224-4507
US

IV. Provider business mailing address

323 INTERLAKE PASS
MCDONOUGH GA
30252-8056
US

V. Phone/Fax

Practice location:
  • Phone: 770-358-8338
  • Fax:
Mailing address:
  • Phone: 678-749-8290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number201732
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: