Healthcare Provider Details

I. General information

NPI: 1790904514
Provider Name (Legal Business Name): LEIGH ANN BAILEY LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W CARMEL DR SUITE 150
CARMEL IN
46032-5877
US

IV. Provider business mailing address

6718 SUNDOWN DR S
INDIANAPOLIS IN
46254-3600
US

V. Phone/Fax

Practice location:
  • Phone: 317-876-7503
  • Fax: 317-575-1190
Mailing address:
  • Phone: 317-298-3108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000563A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: