Provider Demographics
NPI:1609949395
Name:DEVAZIER, DONNA CARLENE (PTA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:CARLENE
Last Name:DEVAZIER
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 1:1504 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-1916
Mailing Address - Country:US
Mailing Address - Phone:870-633-5288
Mailing Address - Fax:
Practice Address - Street 1:620 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3257
Practice Address - Country:US
Practice Address - Phone:870-702-4911
Practice Address - Fax:870-702-6386
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1715225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant