Healthcare Provider Details

I. General information

NPI: 1558730945
Provider Name (Legal Business Name): RACHEL NICOLE ELLISON LMT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 05/08/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6790 COLLEGE STATION DRIVE
WILLIAMSBURG KY
40769
US

IV. Provider business mailing address

PO BOX 483
WILLIAMSBURG KY
40769-0483
US

V. Phone/Fax

Practice location:
  • Phone: 606-515-0390
  • Fax:
Mailing address:
  • Phone: 606-620-6901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberBMTMTH00222474
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1744
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: