Healthcare Provider Details

I. General information

NPI: 1497301121
Provider Name (Legal Business Name): EMILY ANN DYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 MOUNTAIN SHADOWS DR
PURLEAR NC
28665-9400
US

IV. Provider business mailing address

4948 NOTTINGHAM PLACE LN APT 202
WINSTON SALEM NC
27106-4895
US

V. Phone/Fax

Practice location:
  • Phone: 336-907-6812
  • Fax:
Mailing address:
  • Phone: 336-907-6812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4890
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: