Provider Demographics
NPI:1396380473
Name:LACE, OLIVIA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:
Last Name:LACE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 COUNTY ROAD 4254
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-0599
Mailing Address - Country:US
Mailing Address - Phone:901-486-3288
Mailing Address - Fax:
Practice Address - Street 1:3114 FOX RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9322
Practice Address - Country:US
Practice Address - Phone:870-933-9294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4496225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant