Healthcare Provider Details

I. General information

NPI: 1154622462
Provider Name (Legal Business Name): VIVIAN SMITH-SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 STILLWATER DR
JONESBORO AR
72404-9119
US

IV. Provider business mailing address

1900 STILLWATER DR
JONESBORO AR
72404-9119
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-3600
  • Fax: 870-932-3611
Mailing address:
  • Phone: 870-932-3600
  • Fax: 870-932-3611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A072
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: