Basic Information
| Provider Information | |||||||||
| NPI: | 1013552512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11164 CAPTAINS COVE DR | ||||||||
| Address2: | |||||||||
| City: | SODDY DAISY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373795764 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 NORTH STADIUM DR | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708030001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255782050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2019 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.