Provider Demographics
NPI:1427072578
Name:LANDRY, HEATHER A (ATC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:LANDRY
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 1:1802 JACKSON AVE W
Mailing Address - Street 2:#199
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-4361
Mailing Address - Country:US
Mailing Address - Phone:662-801-8522
Mailing Address - Fax:
Practice Address - Street 1:118 FIELDHOUSE, ALL AMERICAN DRIVE
Practice Address - Street 2:THE UNIVERSITY OF MISSISSIPPI
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:662-915-7536
Practice Address - Fax:662-915-5275
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT03552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer