Provider Demographics
NPI:1669908596
Name:SWILLEY, DONNA
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:SWILLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:SWILLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC, LAT, MS
Mailing Address - Street 1:14528 INDIAN TRAILS CIR
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-8607
Mailing Address - Country:US
Mailing Address - Phone:228-669-8018
Mailing Address - Fax:
Practice Address - Street 1:14528 INDIAN TRAILS CIR
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-8607
Practice Address - Country:US
Practice Address - Phone:228-669-8018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMSAT00232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSMS0023ATOtherCERTIFIEDL ATHLETIC TRAINER