Healthcare Provider Details

I. General information

NPI: 1154605061
Provider Name (Legal Business Name): STEPHANIE RENEE' PRIVETT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3114 FOX RD STE A
JONESBORO AR
72404-9322
US

IV. Provider business mailing address

2301 SHEFFIELD DR
JONESBORO AR
72401-8132
US

V. Phone/Fax

Practice location:
  • Phone: 870-933-9294
  • Fax: 870-933-9293
Mailing address:
  • Phone: 870-931-9357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1823
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: