Provider Demographics
NPI:1629299300
Name:HUFFORD, LISA GAY
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GAY
Last Name:HUFFORD
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 1:2310 NW HARVARD WALK
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3950
Mailing Address - Country:US
Mailing Address - Phone:479-531-7092
Mailing Address - Fax:
Practice Address - Street 1:1002 WESTPARK DR
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4173
Practice Address - Country:US
Practice Address - Phone:479-250-4014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8173225100000X
AR1599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist