Provider Demographics
NPI:1164018552
Name:DAVIS, LENA EVELYN (ATC, LAT, MS)
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:EVELYN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ATC, LAT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5037 RIVER ROCK WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2994
Mailing Address - Country:US
Mailing Address - Phone:770-789-0192
Mailing Address - Fax:
Practice Address - Street 1:5037 RIVER ROCK WAY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2994
Practice Address - Country:US
Practice Address - Phone:770-789-0192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0029422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer