Healthcare Provider Details

I. General information

NPI: 1124744859
Provider Name (Legal Business Name): EMILY SHIELD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 INNOVATION PARK DR STE 110
FAIRFAX VA
22031-4870
US

IV. Provider business mailing address

8100 INNOVATION PARK DR # 110
FAIRFAX VA
22031-4870
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-6464
  • Fax:
Mailing address:
  • Phone: 571-472-6464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126003022
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: