Healthcare Provider Details

I. General information

NPI: 1518951862
Provider Name (Legal Business Name): STEPHANIE FAY MAYEAUX MS,ATC,LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 HARDING ST
LAFAYETTE LA
70503-2320
US

IV. Provider business mailing address

2314 KALISTE SALOOM RD NUMBER 508
LAFAYETTE LA
70508-6803
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-3111
  • Fax:
Mailing address:
  • Phone: 337-988-1766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberJ00317
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: