Provider Demographics
NPI:1871076729
Name:LEVERETT, SYDNEY NICOLE (ATC, NREMT)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:NICOLE
Last Name:LEVERETT
Suffix:
Gender:F
Credentials:ATC, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 MALACHI PATH
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4446
Mailing Address - Country:US
Mailing Address - Phone:770-378-3625
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-8835
Practice Address - Country:US
Practice Address - Phone:208-885-1673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR102015262255A2300X
2255A2300X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer