Healthcare Provider Details

I. General information

NPI: 1003657701
Provider Name (Legal Business Name): TATUM ALYSSA HUBBARD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 FOUNDERS DR
CONWAY SC
29526-8658
US

IV. Provider business mailing address

122 OLD PLACE RD
ELLERBE NC
28338-9179
US

V. Phone/Fax

Practice location:
  • Phone: 910-417-9813
  • Fax:
Mailing address:
  • Phone:
  • 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: