=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760110795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOROTHY MICHAELA ROLLINS ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2022
-----------------------------------------------------
Last Update Date | 08/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1269 BARCLAY CIR SE
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-426-2770
-----------------------------------------------------
Fax | 678-322-1144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2309 WOODLANDS DR SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-2495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-734-9111
-----------------------------------------------------
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 | AT004219
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------