Healthcare Provider Details

I. General information

NPI: 1902455686
Provider Name (Legal Business Name): CAITLIN LEE SHELL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY
ALBUQUERQUE NM
87131-2596
US

IV. Provider business mailing address

4300 BRYN MAWR DR NE APT 15
ALBUQUERQUE NM
87107-4832
US

V. Phone/Fax

Practice location:
  • Phone: 505-277-5020
  • Fax:
Mailing address:
  • Phone: 505-659-1462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: