=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487322368
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA PAIGE PERRY MS, LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2021
-----------------------------------------------------
Last Update Date | 09/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 RANDOLPH ST
-----------------------------------------------------
City | EDMONTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42129-8175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-432-2481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1921 SULPHUR WELL CENTER RD
-----------------------------------------------------
City | EDMONTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42129-8222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-670-5389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | TCA966
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------