MEDICARE: ANNA CHRISTINE POWELL ATC, LAT, CSCS

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	AT0175	MS

General Provider Information

NPI Number	:	1780646943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA CHRISTINE POWELL ATC, LAT, CSCS

Provider Business Mailing Address
First Line	:	31 KEYSTONE DR
Second Line	:
City	:	PETAL
State	:	MS
Zip	:	39465-2524
Country	:	US
Telephone Number	:	601-545-3810
Fax Number	:

Provider Business Practice Location Address
First Line	:	1145 HIGHWAY 42
Second Line	:
City	:	PETAL
State	:	MS
Zip	:	39465-9740
Country	:	US
Telephone Number	:	601-544-0500
Fax Number	:	601-544-0505

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

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	07/08/2007

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