MEDICARE: SHELBY NICOLLE WITSCHEN SCHMIDT MIT, LAT, 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	AT6104	TX
2	2255A2300X	Athletic Trainer	AL5464	FL

General Provider Information

NPI Number	:	1962980367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY NICOLLE WITSCHEN SCHMIDT MIT, LAT, ATC

Provider Business Mailing Address
First Line	:	102 WOODBINE CIR
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-3538
Country	:	US
Telephone Number	:	206-777-5328
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 WOODBINE CIR
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-3538
Country	:	US
Telephone Number	:	206-777-5328
Fax Number	:

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

Provider Enumeration Date	:	07/30/2018
Last Update Date	:	09/12/2021

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