Provider Demographics
NPI:1407989783
Name:MCCORKLE, TANGELA (MS,ATC,LAT)
Entity Type:Individual
Prefix:
First Name:TANGELA
Middle Name:
Last Name:MCCORKLE
Suffix:
Gender:F
Credentials:MS,ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 JOHNS CREEK PKWY
Mailing Address - Street 2:A
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6038
Mailing Address - Country:US
Mailing Address - Phone:770-622-5344
Mailing Address - Fax:
Practice Address - Street 1:4255 JOHNS CREEK PKWY
Practice Address - Street 2:A
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6038
Practice Address - Country:US
Practice Address - Phone:770-622-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT001237174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAT001237OtherATHLETIC TRAINER