Healthcare Provider Details

I. General information

NPI: 1831617422
Provider Name (Legal Business Name): KATHRYN RUTH BOYLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2017
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6262 VETERANS PKWY
COLUMBUS GA
31909-3540
US

IV. Provider business mailing address

41 FORD DR SE
ROME GA
30161-8617
US

V. Phone/Fax

Practice location:
  • Phone: 706-266-3866
  • Fax:
Mailing address:
  • Phone: 706-266-6224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: