Healthcare Provider Details

I. General information

NPI: 1265395578
Provider Name (Legal Business Name): KACEY JOYNER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CHAMPS BLVD
MAUMELLE AR
72113-7841
US

IV. Provider business mailing address

1760 DOWN RIVER DR
WOODLAND WA
98674-9699
US

V. Phone/Fax

Practice location:
  • Phone: 501-483-4501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1078
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: