Healthcare Provider Details

I. General information

NPI: 1629299300
Provider Name (Legal Business Name): LISA GAY HUFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 WESTPARK DR
BENTONVILLE AR
72712-4173
US

IV. Provider business mailing address

2310 NW HARVARD WALK
BENTONVILLE AR
72712-3950
US

V. Phone/Fax

Practice location:
  • Phone: 479-250-4014
  • Fax:
Mailing address:
  • Phone: 479-531-7092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8173
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1599
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: