Healthcare Provider Details

I. General information

NPI: 1396365573
Provider Name (Legal Business Name): LEIGH ANN GAINES AT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 VANN DR
JACKSON TN
38305-6018
US

IV. Provider business mailing address

1804 HIGHWAY 45 BYP STE 604
JACKSON TN
38305-4403
US

V. Phone/Fax

Practice location:
  • Phone: 731-984-7640
  • Fax:
Mailing address:
  • Phone: 731-660-7971
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number689
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: