=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184192296
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIELLE MASI ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2018
-----------------------------------------------------
Last Update Date | 11/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 CLAYTON STATE BLVD
-----------------------------------------------------
City | MORROW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-466-4688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530 W 15TH ST
-----------------------------------------------------
City | HAMMONTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08037-8636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-204-8727
-----------------------------------------------------
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 | AT003513
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------