MEDICARE: DR. MYRA ANN STOCKDALE DHSC, ATC, LAT

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	36000285A	IN
2	2255A2300X	Athletic Trainer	AT1347	KY

General Provider Information

NPI Number	:	1245205905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYRA ANN STOCKDALE DHSC, ATC, LAT

Provider Business Mailing Address
First Line	:	231 E GRUNDY AVE
Second Line	:
City	:	SPRINGFIELD
State	:	KY
Zip	:	40069-1114
Country	:	US
Telephone Number	:	812-599-1263
Fax Number	:	502-272-7614

Provider Business Practice Location Address
First Line	:	2001 NEWBURG RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-1863
Country	:	US
Telephone Number	:	502-272-7614
Fax Number	:

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	04/09/2017

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