Healthcare Provider Details

I. General information

NPI: 1942568183
Provider Name (Legal Business Name): AMY WARD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17706 I-30 STE 3
BENTON AR
72019-2930
US

IV. Provider business mailing address

3716 LEGACY VLG DR
BENTON AR
72015
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-4414
  • Fax:
Mailing address:
  • Phone: 501-413-8293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1546
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: