Healthcare Provider Details

I. General information

NPI: 1639201403
Provider Name (Legal Business Name): ERIN MEDLEY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 LILY LN
LAKEMOOR IL
60051-8867
US

IV. Provider business mailing address

533 LILY LN
LAKEMOOR IL
60051-8867
US

V. Phone/Fax

Practice location:
  • Phone: 815-344-5616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number96002376
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: