Provider Demographics
NPI:1114393964
Name:EDWARDS, KACIE (LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:KACIE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:MS
Other - First Name:KACIE
Other - Middle Name:
Other - Last Name:SOMMERFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:LA
Mailing Address - Zip Code:70754-0461
Mailing Address - Country:US
Mailing Address - Phone:225-571-9471
Mailing Address - Fax:
Practice Address - Street 1:1201 S CLEARVIEW PKWY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:LA
Practice Address - Zip Code:70121-1015
Practice Address - Country:US
Practice Address - Phone:225-571-9471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.2003622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer