Healthcare Provider Details

I. General information

NPI: 1366361834
Provider Name (Legal Business Name): HALEY MARIE CANUP LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 CAMEL XING
ALEXANDRIA KY
41001-7507
US

IV. Provider business mailing address

800 WIGEON DR
ALEXANDRIA KY
41001-7437
US

V. Phone/Fax

Practice location:
  • Phone: 859-635-4161
  • Fax:
Mailing address:
  • Phone: 859-905-9108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1911
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: