MEDICARE: MISS CHELSEA L HARRISON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2255A2300X	Athletic Trainer	2601002641	MI

General Provider Information

NPI Number	:	1003448671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CHELSEA L HARRISON

Provider Business Mailing Address
First Line	:	02925 38 50TH ST.
Second Line	:
City	:	BLOOMINGDALE
State	:	MI
Zip	:	49026
Country	:	US
Telephone Number	:	269-303-4473
Fax Number	:

Provider Business Practice Location Address
First Line	:	6716 RAMBLEWOOD CT APT L
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-1760
Country	:	US
Telephone Number	:	269-303-4473
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2020
Last Update Date	:	05/09/2023

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