Provider Demographics
NPI:1568018851
Name:LASATER, STEPHANIE LEA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEA
Last Name:LASATER
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 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:3201 W KEISER AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3467
Practice Address - Country:US
Practice Address - Phone:870-622-0592
Practice Address - Fax:870-622-0782
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR171M00000XMedicaid