Healthcare Provider Details

I. General information

NPI: 1679314256
Provider Name (Legal Business Name): LEMYIAH JEWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3946 ICE WAY
FORT WAYNE IN
46805-1018
US

IV. Provider business mailing address

3946 ICE WAY
FORT WAYNE IN
46805-1018
US

V. Phone/Fax

Practice location:
  • Phone: 317-938-3922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36004145A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: