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General NPI Number Information
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NPI Number | 1659766061
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Entity Type | Individual
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Provider Name | OCTAVIA ROBINSON LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 04/02/2015
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Last Update Date | 12/26/2017
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Provider Practice Location Address
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Address Line | 800 JACKSON AVE E
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City | WYNNE
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State | AR
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Zip | 72396-2225
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Country | US
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Telephone | 870-819-6220
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Fax |
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Provider Business Mailing Address
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Address Line | 27 COUNTY ROAD 366
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City | WYNNE
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State | AR
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Zip | 72396-8548
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Country | US
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Telephone | 870-261-8561
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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 | AT607
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License Number State | AR
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