Healthcare Provider Details

I. General information

NPI: 1992831036
Provider Name (Legal Business Name): SHELBY WYNETTE YEAGER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 ADAMS AVE
SCRANTON PA
18509-1514
US

IV. Provider business mailing address

16 FREDERICK CT
ASHLEY PA
18706-2302
US

V. Phone/Fax

Practice location:
  • Phone: 570-348-6211
  • Fax: 570-961-4730
Mailing address:
  • Phone: 570-239-9363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT001128A
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: