Healthcare Provider Details

I. General information

NPI: 1669139853
Provider Name (Legal Business Name): MICHELLE RENEE ZICKAFOOSE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 BATTLEFIELD PKWY
RINGGOLD GA
30736-5119
US

IV. Provider business mailing address

6770 SWIFF LN
OOLTEWAH TN
37363-5210
US

V. Phone/Fax

Practice location:
  • Phone: 423-624-2696
  • Fax:
Mailing address:
  • Phone: 423-463-5802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7606
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: