Healthcare Provider Details

I. General information

NPI: 1326244526
Provider Name (Legal Business Name): STACEY M QUINN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 SATELLITE BLVD NW SUITE 100
SUWANEE GA
30024-4624
US

IV. Provider business mailing address

100 GALLERIA PKWY SE SUITE 410
ATLANTA GA
30339-3179
US

V. Phone/Fax

Practice location:
  • Phone: 678-957-0757
  • Fax:
Mailing address:
  • Phone: 770-953-6929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001240
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: