=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942681119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIRGINIA MYERS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2015
-----------------------------------------------------
Last Update Date | 06/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1806 LAKEHALL RD
-----------------------------------------------------
City | LAKE VILLAGE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71653-6105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-454-1917
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 639 N LAKESHORE DR
-----------------------------------------------------
City | LAKE VILLAGE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71653-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | S3743
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------