Healthcare Provider Details

I. General information

NPI: 1013653641
Provider Name (Legal Business Name): KAITLIN PHILLIPS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 2ND ST
NEWPORT TN
37821-3703
US

IV. Provider business mailing address

3318 COSBY HWY
COSBY TN
37722-2828
US

V. Phone/Fax

Practice location:
  • Phone: 865-607-4910
  • Fax:
Mailing address:
  • Phone: 865-607-4910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number0000001617
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: