Healthcare Provider Details

I. General information

NPI: 1215334081
Provider Name (Legal Business Name): DANIELLE JEAN STITH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2014
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 KEITH ST NW STE 205
CLEVELAND TN
37312-4324
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 423-559-0444
  • Fax: 423-559-0103
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.003251
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2050
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: