Healthcare Provider Details

I. General information

NPI: 1770210486
Provider Name (Legal Business Name): JOHNNA RAE YEAGER ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 ALTON RD
DANVILLE KY
40422-1126
US

IV. Provider business mailing address

725 ALTON RD
DANVILLE KY
40422-1126
US

V. Phone/Fax

Practice location:
  • Phone: 606-627-8106
  • Fax:
Mailing address:
  • Phone: 606-627-8106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1540
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: