MEDICARE: MRS. LAVONDA ANN HENSLEY L.P.T.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA1904	AR

General Provider Information

NPI Number	:	1609840123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAVONDA ANN HENSLEY L.P.T.A.

Provider Business Mailing Address
First Line	:	RR 2 BOX 5069
Second Line	:
City	:	ROLAND
State	:	OK
Zip	:	74954-9625
Country	:	US
Telephone Number	:	479-650-1123
Fax Number	:

Provider Business Practice Location Address
First Line	:	RR 2 BOX 5069
Second Line	:
City	:	ROLAND
State	:	OK
Zip	:	74954-9625
Country	:	US
Telephone Number	:	479-650-1123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	07/09/2007

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