Basic Information
| Provider Information | |||||||||
| NPI: | 1235761719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | LAT, ATC, CEAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 502 PLUM NEARLY LN APT K | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284032759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179264689 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17230 US HIGHWAY 17 N STE 218 | ||||||||
| Address2: | |||||||||
| City: | HAMPSTEAD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284437466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108211506 | ||||||||
| FaxNumber: | 9108211508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2020 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 006752 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 4291 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 2000028027 | 01 | PA | CERTIFIED ATHLETIC TRAINER | OTHER | 4291 | 01 | NC | LICENSED ATHLETIC TRAINER | OTHER | 006752 | 01 | PA | LICENSED ATHLETIC TRAINER | OTHER |