Healthcare Provider Details

I. General information

NPI: 1245753698
Provider Name (Legal Business Name): CAITLIN E BROWN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CAPITOL ST
CLINTON MS
39056-4026
US

IV. Provider business mailing address

1507 RESERVE DR
CLINTON MS
39056-5663
US

V. Phone/Fax

Practice location:
  • Phone: 601-925-3000
  • Fax:
Mailing address:
  • Phone: 901-634-6146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0822
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: