MEDICARE: KACEY JOYNER ATC

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	1078	AR

General Provider Information

NPI Number	:	1265395578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KACEY JOYNER ATC

Provider Business Mailing Address
First Line	:	1760 DOWN RIVER DR
Second Line	:
City	:	WOODLAND
State	:	WA
Zip	:	98674-9699
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 CHAMPS BLVD
Second Line	:
City	:	MAUMELLE
State	:	AR
Zip	:	72113-7841
Country	:	US
Telephone Number	:	501-483-4501
Fax Number	:

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

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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