Healthcare Provider Details

I. General information

NPI: 1649872136
Provider Name (Legal Business Name): MARANDA LIGHT OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 GRANT AVE
JONESBORO AR
72401-6155
US

IV. Provider business mailing address

1801 GRANT AVE
JONESBORO AR
72401-6155
US

V. Phone/Fax

Practice location:
  • Phone: 870-974-9114
  • Fax:
Mailing address:
  • Phone: 870-974-9114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1170
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: