Provider Demographics
NPI:1891181822
Name:WOFFORD, TAMANTHA (MED, ATC/L)
Entity Type:Individual
Prefix:
First Name:TAMANTHA
Middle Name:
Last Name:WOFFORD
Suffix:
Gender:F
Credentials:MED, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 REINHARDT CIR
Mailing Address - Street 2:
Mailing Address - City:WALESKA
Mailing Address - State:GA
Mailing Address - Zip Code:30183-2981
Mailing Address - Country:US
Mailing Address - Phone:770-720-9321
Mailing Address - Fax:
Practice Address - Street 1:7300 REINHARDT CIR
Practice Address - Street 2:
Practice Address - City:WALESKA
Practice Address - State:GA
Practice Address - Zip Code:30183-2981
Practice Address - Country:US
Practice Address - Phone:770-720-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL39632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2000004617OtherBOC ATHLETIC TRAINER