MEDICARE: KEELY L BURNHAM ATC

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	AT0000000980	TN

General Provider Information

NPI Number	:	1104938794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEELY L BURNHAM ATC

Provider Business Mailing Address
First Line	:	300 ROYAL OAKS BLVD APT 1706
Second Line	:
City	:	FRANKLIN
State	:	TN
Zip	:	37067-4445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	394 HARDING PL STE 200
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37211-3980
Country	:	US
Telephone Number	:	615-834-4708
Fax Number	:

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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