Healthcare Provider Details

I. General information

NPI: 1437354438
Provider Name (Legal Business Name): JILL M HARTMAN LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N. CAMDEN RD
WINGATE NC
28174-9644
US

IV. Provider business mailing address

211A E. WILSON ST. CAMPUS BOX 2503
WINGATE NC
28174-9664
US

V. Phone/Fax

Practice location:
  • Phone: 704-233-8165
  • Fax:
Mailing address:
  • Phone: 704-363-9851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1283
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: