Healthcare Provider Details

I. General information

NPI: 1053415760
Provider Name (Legal Business Name): SUSAN MICHELE PELL ATC, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL WAY SUITE 100
SOMERSET KY
42503-2872
US

IV. Provider business mailing address

350 HOSPITAL WAY SUITE 100
SOMERSET KY
42503-2872
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-2628
  • Fax: 606-451-2630
Mailing address:
  • Phone: 606-451-2628
  • Fax: 606-451-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC032
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001161
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: