Healthcare Provider Details

I. General information

NPI: 1043799141
Provider Name (Legal Business Name): COLLEEN FUSSELL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 BUCKEYE DR
NELSONVILLE OH
45764-9591
US

IV. Provider business mailing address

363 RICHLAND AVE APT 280
ATHENS OH
45701-3281
US

V. Phone/Fax

Practice location:
  • Phone: 407-595-7793
  • Fax:
Mailing address:
  • Phone: 407-595-7793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberGUG3YD
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5693
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: