Provider Demographics
NPI:1083750533
Name:PURCELL, LAURA FAWN (MPT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:FAWN
Last Name:PURCELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4774 W CANYON RUN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-3401
Mailing Address - Country:US
Mailing Address - Phone:479-857-0644
Mailing Address - Fax:
Practice Address - Street 1:363 MCKNIGHT AVE
Practice Address - Street 2:
Practice Address - City:WEST FORK
Practice Address - State:AR
Practice Address - Zip Code:72774
Practice Address - Country:US
Practice Address - Phone:479-751-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P8343235Z00000X
PT2255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARBLUE CROSSOther5U688