Provider Demographics
NPI:1376092874
Name:MCBRAYER, CHIQUITTA LEOLA NICOLE (LAT ATC)
Entity Type:Individual
Prefix:
First Name:CHIQUITTA
Middle Name:LEOLA NICOLE
Last Name:MCBRAYER
Suffix:
Gender:F
Credentials:LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9602 HOLT SPRINGER RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-8162
Mailing Address - Country:US
Mailing Address - Phone:256-460-7111
Mailing Address - Fax:
Practice Address - Street 1:211 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:RED BAY
Practice Address - State:AL
Practice Address - Zip Code:35582-3858
Practice Address - Country:US
Practice Address - Phone:256-460-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-25
Last Update Date:2016-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2000014549OtherBOARD OF CERTIFICATION NUMBER
AL8123035OtherDRIVERS LICENSE
AL1524OtherSTATE ATHLETIC TRAINER LICENSE