MEDICARE: MAELEE CORINNA AVERETT

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	363A00000X	Physician Assistant	12724	GA

General Provider Information

NPI Number	:	1578251617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAELEE CORINNA AVERETT

Provider Business Mailing Address
First Line	:	93019 HARBOR CT
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-0814
Country	:	US
Telephone Number	:	478-357-2308
Fax Number	:

Provider Business Practice Location Address
First Line	:	93019 HARBOR CT
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-0814
Country	:	US
Telephone Number	:	478-357-2308
Fax Number	:

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

Provider Enumeration Date	:	04/26/2023
Last Update Date	:	12/16/2025

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Directions to “ MAELEE CORINNA AVERETT ” Practice Location

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