Healthcare Provider Details

I. General information

NPI: 1639781768
Provider Name (Legal Business Name): ALLY NICOLE HERRINGTON MS, ATC,LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 STANLEY RD NW
KENNESAW GA
30152-4359
US

IV. Provider business mailing address

1100 CIRCLE 75 PKWY SE STE 1400
ATLANTA GA
30339-3067
US

V. Phone/Fax

Practice location:
  • Phone: 770-578-0182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberAT002822
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: