Healthcare Provider Details

I. General information

NPI: 1770548208
Provider Name (Legal Business Name): MELISSA MICHELLE KLAMM ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 SHELBYVILLE RD SECOND FLOOR
LOUISVILLE KY
40207-3205
US

IV. Provider business mailing address

9701 LONG RIFLE LN
LOUISVILLE KY
40291-3171
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-5750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT614
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: