Healthcare Provider Details

I. General information

NPI: 1053902478
Provider Name (Legal Business Name): EMMA LEDBETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N UNIVERSITY ST
NORMAL IL
61761-4402
US

IV. Provider business mailing address

509 GRANT ST
NORMAL IL
61761-1510
US

V. Phone/Fax

Practice location:
  • Phone: 574-309-0778
  • Fax:
Mailing address:
  • Phone: 574-309-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: