1134758527 NPI number — MECHELLE SUEZETTE NORRIS MS, LAT, ATC

Table of content: MECHELLE SUEZETTE NORRIS MS, LAT, ATC (NPI 1134758527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134758527 NPI number — MECHELLE SUEZETTE NORRIS MS, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORRIS
Provider First Name:
MECHELLE
Provider Middle Name:
SUEZETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134758527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5423 QUEST CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALE CITY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-980-5117
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LOYOLA UNIVERSITY MARYLAND ATHLETICS
Provider Second Line Business Practice Location Address:
4501 N CHARLES ST.
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-617-5276
Provider Business Practice Location Address Fax Number:
410-617-5709
Provider Enumeration Date:
04/07/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2081S0010X , with the licence number:  A0001034 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)