Provider Demographics
NPI:1487113031
Name:SNYDER, KAITLIN INGRAM (DPT)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:INGRAM
Last Name:SNYDER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:ASHLEY
Other - Last Name:INGRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 AVIGNON DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5120
Mailing Address - Country:US
Mailing Address - Phone:601-605-6777
Mailing Address - Fax:601-607-1362
Practice Address - Street 1:600 S PEAR ORCHARD RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4221
Practice Address - Country:US
Practice Address - Phone:601-856-2205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist