MEDICARE: LYNNETTE YVONNE JOHNSON 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	AT0018	MS

General Provider Information

NPI Number	:	1821027194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNNETTE YVONNE JOHNSON ATC

Provider Business Mailing Address
First Line	:	1207 OLD LAKE CV
Second Line	:
City	:	OXFORD
State	:	MS
Zip	:	38655-8152
Country	:	US
Telephone Number	:	662-236-2368
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 COLISUEM DRIVE
Second Line	:	GILLOM SPORTS CENTER
City	:	UNIVERSITY
State	:	MS
Zip	:	38677
Country	:	US
Telephone Number	:	662-915-7303
Fax Number	:	662-915-5648

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	07/08/2007

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