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General NPI Number Information
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NPI Number | 1588371819
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Entity Type | Individual
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Provider Name | KEONNA SHADAE KING BS, LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 11/07/2022
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Last Update Date | 11/07/2022
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Provider Practice Location Address
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Address Line | 4900 MERIDIAN ST NW
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City | NORMAL
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State | AL
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Zip | 35762-7500
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Country | US
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Telephone | 256-372-8457
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Fax |
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Provider Business Mailing Address
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Address Line | 710 JULIA ST NW APT 10
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City | HUNTSVILLE
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State | AL
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Zip | 35816-3741
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Country | US
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Telephone | 334-322-8973
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2530
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License Number State | AL
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