Provider Demographics
NPI:1568797793
Name:FENTON, VERONICA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:MARIE
Last Name:FENTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7221 FORK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-5153
Mailing Address - Country:US
Mailing Address - Phone:870-741-9607
Mailing Address - Fax:
Practice Address - Street 1:7221 FORK CREEK RD
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-5153
Practice Address - Country:US
Practice Address - Phone:870-741-9607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR178461795Medicaid