Healthcare Provider Details

I. General information

NPI: 1720747215
Provider Name (Legal Business Name): MAKAYLA RAEANNE FLOREZ DAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2021
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JENSEN HUMAN PERFORMANCE CENTER, S DIVISION ST
FORT LEWIS WA
98433
US

IV. Provider business mailing address

15420 CALLIE AVE SE
YELM WA
98597-6621
US

V. Phone/Fax

Practice location:
  • Phone: 910-709-8390
  • Fax:
Mailing address:
  • Phone: 910-709-8390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4897
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA161568584
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: