=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558260448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COURTNEY NICOLE FANELLE MS, ATC, LAT,
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2026
-----------------------------------------------------
Last Update Date | 11/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 651 N OLD COACHMAN RD
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33765-2321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-828-2232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 AKRON AVE
-----------------------------------------------------
City | HADDON TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08108-2408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-828-2232
-----------------------------------------------------
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 | 7394
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 25MT00334000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------