Healthcare Provider Details

I. General information

NPI: 1679075923
Provider Name (Legal Business Name): SHELBY NICOLE FANKHAUSER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4249 HIGHWAY 411
MADISONVILLE TN
37354-1544
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
BIRMINGHAM AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 423-442-4034
  • Fax: 423-442-6463
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2112
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: