Healthcare Provider Details

I. General information

NPI: 1427072578
Provider Name (Legal Business Name): HEATHER A LANDRY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 FIELDHOUSE, ALL AMERICAN DRIVE THE UNIVERSITY OF MISSISSIPPI
UNIVERSITY MS
38677
US

IV. Provider business mailing address

1802 JACKSON AVE W #199
OXFORD MS
38655-4361
US

V. Phone/Fax

Practice location:
  • Phone: 662-915-7536
  • Fax: 662-915-5275
Mailing address:
  • Phone: 662-801-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0355
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: