Healthcare Provider Details

I. General information

NPI: 1659927473
Provider Name (Legal Business Name): MCKENNA EMILY PATRICK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 E WILSON ST
WINGATE NC
28174
US

IV. Provider business mailing address

220 N CAMDEN RD
WINGATE NC
28174-9644
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4365
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: