Basic Information
| Provider Information | |||||||||
| NPI: | 1174198816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHERROD | ||||||||
| FirstName: | ALEXIS | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 PEACHTREE RD UNIT 311 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303412437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736770299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2505 NEWPOINT PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782577078 | ||||||||
| FaxNumber: | 6786692619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2021 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT002868 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | AT002868 | 01 | GA | SECRETARY OF STATE (GA) ATHLETIC TRAINER LICENSE | OTHER |