Provider Demographics
NPI:1669998720
Name:HARRELL, AMBER LOUISE (ATC)
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:LOUISE
Last Name:HARRELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2194 CLUB LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-4600
Mailing Address - Country:US
Mailing Address - Phone:904-537-2836
Mailing Address - Fax:
Practice Address - Street 1:1700 OLD MIDDLEBURG RD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1232
Practice Address - Country:US
Practice Address - Phone:904-693-7620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-20
Last Update Date:2017-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL50232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer