=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023667268
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELBY BLEY LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2019
-----------------------------------------------------
Last Update Date | 09/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 35TH LN
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81006-9426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-948-3351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2726 ATLANTA AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81003-1341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-251-3631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT.0000578
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------