Provider Demographics
NPI:1114397502
Name:FENDLEY, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:FENDLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 WILSON LOOP
Mailing Address - Street 2:
Mailing Address - City:WARD
Mailing Address - State:AR
Mailing Address - Zip Code:72176-8656
Mailing Address - Country:US
Mailing Address - Phone:501-941-5630
Mailing Address - Fax:501-353-2599
Practice Address - Street 1:1500 WILSON LOOP
Practice Address - Street 2:
Practice Address - City:WARD
Practice Address - State:AR
Practice Address - Zip Code:72176-8656
Practice Address - Country:US
Practice Address - Phone:501-941-5630
Practice Address - Fax:501-353-2599
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2837225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210596721Medicaid