Provider Demographics
NPI:1518431345
Name:BLEDSOE, PEYTON LEA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:LEA
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BAYOU BEND DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70364-1101
Mailing Address - Country:US
Mailing Address - Phone:985-870-3139
Mailing Address - Fax:
Practice Address - Street 1:102 BAYOU BEND DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70364-1101
Practice Address - Country:US
Practice Address - Phone:985-870-3139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA3129122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program