Provider Demographics
NPI:1376767210
Name:DAVIS, TINA LEAH (ATC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LEAH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:LEAH
Other - Last Name:NIEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:4601 SADDLE GATE LN
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5286
Mailing Address - Country:US
Mailing Address - Phone:770-975-8995
Mailing Address - Fax:
Practice Address - Street 1:4601 SADDLE GATE LN
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-5286
Practice Address - Country:US
Practice Address - Phone:770-975-8995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0008872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer