Healthcare Provider Details

I. General information

NPI: 1194360008
Provider Name (Legal Business Name): SHAYLEE JADE FOUTS MED, ATC, LAT, PES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7050 AIR DEPOT BLVD
TINKER AFB OK
73145-8716
US

IV. Provider business mailing address

3731 STONERIDGE DR
FLINT TX
75762-6942
US

V. Phone/Fax

Practice location:
  • Phone: 405-734-9595
  • Fax:
Mailing address:
  • Phone: 308-991-6306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT7166
License Number StateTX

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: