=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699213645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIN KENNEDY ATC, LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2017
-----------------------------------------------------
Last Update Date | 02/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 TENNESSEE AVE
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70402-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-549-2276
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14234 WOODLANDS DR #88
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70401-7342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-766-2360
-----------------------------------------------------
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 | ATH.200210
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------