=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508486630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLA LYNN FIVEASH ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2020
-----------------------------------------------------
Last Update Date | 05/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1816 HUNTSVILLE HWY
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37334-3787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-228-5585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1185 COUNTY ROAD 1000 W
-----------------------------------------------------
City | LINTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 2385
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 36003559A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------