Healthcare Provider Details

I. General information

NPI: 1073644589
Provider Name (Legal Business Name): MICHELLE MARIE LESPERANCE LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 BROADLEAF RD
SUMMERFIELD NC
27358-7825
US

IV. Provider business mailing address

3301 N BROOK DR
GREENSBORO NC
27410-8368
US

V. Phone/Fax

Practice location:
  • Phone: 336-404-8419
  • Fax:
Mailing address:
  • Phone: 336-272-7192
  • Fax: 336-217-7237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0554
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number322419423
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: