Healthcare Provider Details

I. General information

NPI: 1336179290
Provider Name (Legal Business Name): MARTHA SIMMS MIKELL MSED, ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 AUGUSTA FARMS RD
STUARTS DRAFT VA
24477-3200
US

IV. Provider business mailing address

45 FLORY AVE
STUARTS DRAFT VA
24477-2944
US

V. Phone/Fax

Practice location:
  • Phone: 540-886-8500
  • Fax:
Mailing address:
  • Phone: 540-337-2638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000100
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: