Provider Demographics
NPI:1669862884
Name:CARLSON, AVERY BRIANNE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:BRIANNE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-3482
Mailing Address - Country:US
Mailing Address - Phone:605-880-8886
Mailing Address - Fax:
Practice Address - Street 1:36 5TH ST N
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3482
Practice Address - Country:US
Practice Address - Phone:605-880-8886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-5312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer