MEDICARE: MRS. ALICIA MARIE INMON MSE, ATC, LAT

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	2007018044	MO

General Provider Information

NPI Number	:	1578528840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALICIA MARIE INMON MSE, ATC, LAT

Provider Business Mailing Address
First Line	:	2135 S FREMONT AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2239
Country	:	US
Telephone Number	:	417-820-7990
Fax Number	:	417-820-8734

Provider Business Practice Location Address
First Line	:	2135 S FREMONT AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2239
Country	:	US
Telephone Number	:	417-820-7990
Fax Number	:	417-820-8734

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

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	05/01/2012

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