=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881215325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON M SOARES ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2020
-----------------------------------------------------
Last Update Date | 05/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 228 EVERETT DR
-----------------------------------------------------
City | SNEADS FERRY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28460-8528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-487-6450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 228 EVERETT DR
-----------------------------------------------------
City | SNEADS FERRY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28460-8528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-487-6450
-----------------------------------------------------
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 | LAT-4090
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------