=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821751595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA FELTS PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2021
-----------------------------------------------------
Last Update Date | 01/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1065 CLAYTON ST STE 9
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032-4335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-328-5878
-----------------------------------------------------
Fax | 501-336-0119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1168
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72033-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-328-5878
-----------------------------------------------------
Fax | 501-336-0119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT1309
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------