MEDICARE: MARY NICOLE HIGHT B.S., A.T.C., L.A.T.

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	AT6043	TX

General Provider Information

NPI Number	:	1295199776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY NICOLE HIGHT B.S., A.T.C., L.A.T.

Provider Business Mailing Address
First Line	:	3225 WOODLAND PARK DR
Second Line	:	#1471
City	:	HOUSTON
State	:	TX
Zip	:	77082-7603
Country	:	US
Telephone Number	:	936-446-7299
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 WOODLAND PARK DR
Second Line	:	#1471
City	:	HOUSTON
State	:	TX
Zip	:	77082-7603
Country	:	US
Telephone Number	:	936-446-7299
Fax Number	:

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

Provider Enumeration Date	:	04/11/2016
Last Update Date	:	04/11/2016

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