Provider Demographics
NPI:1760719058
Name:STALEY, JANA L (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:L
Last Name:STALEY
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 1:138 DUBLIN SQUARE RD STE A
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-8601
Mailing Address - Country:US
Mailing Address - Phone:336-626-3700
Mailing Address - Fax:336-626-4100
Practice Address - Street 1:138 DUBLIN SQUARE RD STE A
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-8601
Practice Address - Country:US
Practice Address - Phone:336-626-3700
Practice Address - Fax:336-626-4100
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC080702217OtherBOARD OF CERTIFICATION
NC1393OtherNORTH CAROLINA BOARD OF ATHLETIC TRAINER