=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073063947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE COLLIER LAT ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2016
-----------------------------------------------------
Last Update Date | 10/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1408 WALKER AVE ROOM 136
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27412-5020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-334-5925
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6400 OLD OAK RIDGE RD APT I1
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27410-8539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-409-0947
-----------------------------------------------------
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 | LAT-2516
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------