=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952110751
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALAIYAH CAMPBELL LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2025
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9375 CONWAY DR BLDG 3425
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31905-5920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-544-8732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 447 W LONGLEAF DR APT 1304
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36832-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 2954
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------