Healthcare Provider Details

I. General information

NPI: 1972909000
Provider Name (Legal Business Name): JOAN JAMES ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11407 RIDGE LN
MONROVIA MD
21770-9501
US

IV. Provider business mailing address

11407 RIDGE LN
MONROVIA MD
21770-9501
US

V. Phone/Fax

Practice location:
  • Phone: 301-802-1912
  • Fax:
Mailing address:
  • Phone: 301-802-1912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002018
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: