MEDICARE: LAURA ASHLEY WIND AT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2082	TN

General Provider Information

NPI Number	:	1154728913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA ASHLEY WIND AT

Provider Business Mailing Address
First Line	:	6397 LEE HWY STE 300
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-4915
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:	423-238-3473

Provider Business Practice Location Address
First Line	:	6736 CHARLOTTE PIKE STE 102
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37209-4290
Country	:	US
Telephone Number	:	615-942-7783
Fax Number	:	615-942-7886

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2014
Last Update Date	:	05/06/2019

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