Healthcare Provider Details

I. General information

NPI: 1013165265
Provider Name (Legal Business Name): MS. VICKI LEANN HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2607 TRACEE WAY
SPRINGDALE AR
72762-2829
US

IV. Provider business mailing address

2607 TRACEE WAY
SPRINGDALE AR
72762-2829
US

V. Phone/Fax

Practice location:
  • Phone: 479-629-0663
  • Fax:
Mailing address:
  • Phone: 479-629-0663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1607
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: