=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386284495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLYNN JOANN ROLETT LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2020
-----------------------------------------------------
Last Update Date | 01/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 219 INDUSTRIAL PARK ST
-----------------------------------------------------
City | GORDO
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35466-2068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-364-1003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 ENERGY CENTER BLVD APT 3414
-----------------------------------------------------
City | NORTHPORT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35473-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-264-5787
-----------------------------------------------------
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 | 2163
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------