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General NPI Number Information
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NPI Number | 1457875205
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Entity Type | Individual
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Provider Name | MERRISA KENNEDY HERALDSON ATC
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Gender | Female
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Dates
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Enumeration Date | 08/02/2017
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Last Update Date | 08/02/2017
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Provider Practice Location Address
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Address Line | 400 E COLLEGE ST
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City | GEORGETOWN
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State | KY
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Zip | 40324-1628
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Country | US
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Telephone | 859-806-6187
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Fax |
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Provider Business Mailing Address
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Address Line | 101 CAROLINE PATH APT 5
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City | GEORGETOWN
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State | KY
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Zip | 40324-0528
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Country | US
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Telephone | 502-609-7625
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | TCA572
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License Number State | KY
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