Provider Demographics
NPI:1497711592
Name:FORD, LAUREN PRUITT (PTA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:PRUITT
Last Name:FORD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LAUREN
Other - Last Name:PRUITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1200 N JAMES ST STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-3167
Mailing Address - Country:US
Mailing Address - Phone:501-241-0410
Mailing Address - Fax:
Practice Address - Street 1:1200 N JAMES ST STE A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3167
Practice Address - Country:US
Practice Address - Phone:501-241-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2046225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157635721Medicaid