Healthcare Provider Details

I. General information

NPI: 1295427185
Provider Name (Legal Business Name): MIKAYLA COGHILL LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CHANCELLOR PL
FREDERICKSBURG VA
22401-2104
US

IV. Provider business mailing address

307 CHANCELLOR PL
FREDERICKSBURG VA
22401-2104
US

V. Phone/Fax

Practice location:
  • Phone: 540-845-7570
  • Fax:
Mailing address:
  • Phone: 540-845-7570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2908
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2908
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: