Provider Demographics
NPI:1235565888
Name:KOSSMAN, MELISSA K (PHD, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:K
Last Name:KOSSMAN
Suffix:
Gender:F
Credentials:PHD, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 E FORDHAM DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1913
Mailing Address - Country:US
Mailing Address - Phone:919-807-9077
Mailing Address - Fax:
Practice Address - Street 1:118 COLLEGE DRIVE #5122
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406-2701
Practice Address - Country:US
Practice Address - Phone:919-807-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-15
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT-09452255A2300X
174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer