Healthcare Provider Details

I. General information

NPI: 1760719058
Provider Name (Legal Business Name): JANA L STALEY LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 DUBLIN SQUARE RD STE A
ASHEBORO NC
27203-8601
US

IV. Provider business mailing address

138 DUBLIN SQUARE RD STE A
ASHEBORO NC
27203-8601
US

V. Phone/Fax

Practice location:
  • Phone: 336-626-3700
  • Fax: 336-626-4100
Mailing address:
  • Phone: 336-626-3700
  • Fax: 336-626-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1393
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: