MEDICARE: DR. JAMIE LYNN MOUL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	0324	NC

General Provider Information

NPI Number	:	1043230121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMIE LYNN MOUL

Provider Business Mailing Address
First Line	:	227 WINDRIDGE DR
Second Line	:
City	:	SUGAR GROVE
State	:	NC
Zip	:	28679-9256
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 RIVERS STREET
Second Line	:	HOLMES CONVOCATION CENTER
City	:	BOONE
State	:	NC
Zip	:	28608-0001
Country	:	US
Telephone Number	:	828-262-7630
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	04/09/2014

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