Provider Demographics
NPI:1669687430
Name:EIDE, LETISHIA LYNE (LMT)
Entity Type:Individual
Prefix:
First Name:LETISHIA
Middle Name:LYNE
Last Name:EIDE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SMITH LOOP
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2092
Mailing Address - Country:US
Mailing Address - Phone:501-467-4445
Mailing Address - Fax:
Practice Address - Street 1:910 DYER ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-5253
Practice Address - Country:US
Practice Address - Phone:501-467-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4697174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist