MEDICARE: MS. PAMELA KNIGHT GUIDRY MS, 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	J00135	LA

General Provider Information

NPI Number	:	1841494580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PAMELA KNIGHT GUIDRY MS, ATC, LAT

Provider Business Mailing Address
First Line	:	111 MALLARD ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-6515
Country	:	US
Telephone Number	:	337-474-0349
Fax Number	:	337-477-8964

Provider Business Practice Location Address
First Line	:	PO BOX 91705
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70609-0001
Country	:	US
Telephone Number	:	337-477-0248
Fax Number	:

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

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	07/08/2007

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