Healthcare Provider Details

I. General information

NPI: 1609840123
Provider Name (Legal Business Name): LAVONDA ANN HENSLEY L.P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 2 BOX 5069
ROLAND OK
74954-9625
US

IV. Provider business mailing address

RR 2 BOX 5069
ROLAND OK
74954-9625
US

V. Phone/Fax

Practice location:
  • Phone: 479-650-1123
  • Fax:
Mailing address:
  • Phone: 479-650-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1904
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: