Provider Demographics
NPI:1457875205
Name:HERALDSON, MERRISA KENNEDY (ATC)
Entity Type:Individual
Prefix:
First Name:MERRISA
Middle Name:KENNEDY
Last Name:HERALDSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CAROLINE PATH APT 5
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-0528
Mailing Address - Country:US
Mailing Address - Phone:502-609-7625
Mailing Address - Fax:
Practice Address - Street 1:400 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1628
Practice Address - Country:US
Practice Address - Phone:859-806-6187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTCA5722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty