Healthcare Provider Details

I. General information

NPI: 1962560995
Provider Name (Legal Business Name): COURTNEY LAINE MATYJA AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY L WALLIS

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 S GERMAN LN STE 2
CONWAY AR
72034-6479
US

IV. Provider business mailing address

855 S GERMAN LN
CONWAY AR
72034-6334
US

V. Phone/Fax

Practice location:
  • Phone: 501-205-1215
  • Fax: 501-205-1250
Mailing address:
  • Phone: 501-205-1215
  • Fax: 501-205-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1918
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number284
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: