Healthcare Provider Details

I. General information

NPI: 1821027194
Provider Name (Legal Business Name): LYNNETTE YVONNE JOHNSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COLISUEM DRIVE GILLOM SPORTS CENTER
UNIVERSITY MS
38677
US

IV. Provider business mailing address

1207 OLD LAKE CV
OXFORD MS
38655-8152
US

V. Phone/Fax

Practice location:
  • Phone: 662-915-7303
  • Fax: 662-915-5648
Mailing address:
  • Phone: 662-236-2368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0018
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: