Provider Demographics
NPI:1235761719
Name:HARRIS, SUZANNE ELIZABETH (LAT, ATC, CEAS)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LAT, ATC, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 PLUM NEARLY LN APT K
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2759
Mailing Address - Country:US
Mailing Address - Phone:717-926-4689
Mailing Address - Fax:
Practice Address - Street 1:17230 US HIGHWAY 17 N STE 218
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-7466
Practice Address - Country:US
Practice Address - Phone:910-821-1506
Practice Address - Fax:910-821-1508
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0067522255A2300X
NC42912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2000028027OtherCERTIFIED ATHLETIC TRAINER
NC4291OtherLICENSED ATHLETIC TRAINER
PA006752OtherLICENSED ATHLETIC TRAINER