Provider Demographics
NPI:1558863647
Name:LAMB, GWEN MICHELLE
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MICHELLE
Last Name:LAMB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 W WAGON WHEEL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-9019
Mailing Address - Country:US
Mailing Address - Phone:479-871-4743
Mailing Address - Fax:
Practice Address - Street 1:1801 FOREST HILLS BLVD STE 205
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72715-3071
Practice Address - Country:US
Practice Address - Phone:479-855-9348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3854225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant