Provider Demographics
NPI:1407204217
Name:HODEAUX, KENNA MEGAN (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:MEGAN
Last Name:HODEAUX
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 W BERRY ST
Mailing Address - Street 2:APT #4
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-1875
Mailing Address - Country:US
Mailing Address - Phone:520-909-7768
Mailing Address - Fax:
Practice Address - Street 1:1201 LEROY POND DRIVE
Practice Address - Street 2:SPORTS MEDICINE DEPARTMENT
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701
Practice Address - Country:US
Practice Address - Phone:479-575-4018
Practice Address - Fax:479-575-6525
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer