=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134006182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILLY MARIE SHUPE ATC, LAT, OTC, OT-SC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2025
-----------------------------------------------------
Last Update Date | 08/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 487 WINN WAY STE 100
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-251-2090
-----------------------------------------------------
Fax | 404-251-4471
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 487 WINN WAY STE 100
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-251-2090
-----------------------------------------------------
Fax | 404-251-4471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | 24-0912
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT004124
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------