Healthcare Provider Details

I. General information

NPI: 1891907465
Provider Name (Legal Business Name): MICHELLE RENEE STAFFORD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9988 W UNION RD
MEDWAY OH
45341-9747
US

IV. Provider business mailing address

9988 W UNION RD
MEDWAY OH
45341-9747
US

V. Phone/Fax

Practice location:
  • Phone: 937-849-1135
  • Fax:
Mailing address:
  • Phone: 937-849-1135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002109
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: