Healthcare Provider Details

I. General information

NPI: 1851742027
Provider Name (Legal Business Name): MELISSA SUZANNE FIELDS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 01/25/2020
Certification Date: 01/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-5600
  • Fax:
Mailing address:
  • Phone: 859-301-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberAT1375
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAT1375
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT1375
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberAT1375
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1375
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: