Healthcare Provider Details

I. General information

NPI: 1164263877
Provider Name (Legal Business Name): ASHLEY MYERS MITCHELL LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 LAKELAND DR
FLOWOOD MS
39232-9583
US

IV. Provider business mailing address

326 FAIRVIEW DR
BRANDON MS
39047-7083
US

V. Phone/Fax

Practice location:
  • Phone: 769-251-1166
  • Fax:
Mailing address:
  • Phone: 601-214-8716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1214
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: