MEDICARE: MS. AMBER LOUISE HARRELL ATC

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	AL5023	FL

General Provider Information

NPI Number	:	1669998720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMBER LOUISE HARRELL ATC

Provider Business Mailing Address
First Line	:	2194 CLUB LAKE DR
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-4600
Country	:	US
Telephone Number	:	904-537-2836
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 OLD MIDDLEBURG RD N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-1232
Country	:	US
Telephone Number	:	904-693-7620
Fax Number	:

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

Provider Enumeration Date	:	08/20/2017
Last Update Date	:	08/20/2017

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