Healthcare Provider Details

I. General information

NPI: 1679314140
Provider Name (Legal Business Name): KAITLIN DANIELLE HORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 5TH ST
BLUE MOUNTAIN MS
38610-8981
US

IV. Provider business mailing address

1003 FOREST VIEW CV
HICKORY FLAT MS
38633-9533
US

V. Phone/Fax

Practice location:
  • Phone: 662-685-4771
  • Fax:
Mailing address:
  • Phone: 662-507-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1217
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: