Healthcare Provider Details

I. General information

NPI: 1457753667
Provider Name (Legal Business Name): LILA DIANE STANDEFER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 S LAUREL CROSSING CIR
ROGERS AR
72758-9206
US

IV. Provider business mailing address

2700 S LAUREL CROSSING CIR
ROGERS AR
72758-9206
US

V. Phone/Fax

Practice location:
  • Phone: 479-420-4633
  • Fax:
Mailing address:
  • Phone: 479-420-4633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR88294
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: