Healthcare Provider Details

I. General information

NPI: 1962539338
Provider Name (Legal Business Name): LACEY LEANN WESTON LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

889 EAST MAIN ST.
MELBOURNE AR
72556
US

IV. Provider business mailing address

P.O. BOX 134
SAGE AR
72573
US

V. Phone/Fax

Practice location:
  • Phone: 870-368-4586
  • Fax: 870-368-4587
Mailing address:
  • Phone: 870-291-0361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2053
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: