Healthcare Provider Details

I. General information

NPI: 1093433385
Provider Name (Legal Business Name): ALLIE ROSE HAWKINS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 KENNEDY DR
MELISSA TX
75454-2500
US

IV. Provider business mailing address

2700 KENNEDY DR
MELISSA TX
75454-2500
US

V. Phone/Fax

Practice location:
  • Phone: 951-790-6184
  • Fax:
Mailing address:
  • Phone: 951-790-6184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAT7428
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: