Provider Demographics
NPI:1710443064
Name:LAIRD, PAMELA JO (PT, CNA, OT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JO
Last Name:LAIRD
Suffix:
Gender:F
Credentials:PT, CNA, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1466
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-1466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:64 W CADRON RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENBRIER
Practice Address - State:AR
Practice Address - Zip Code:72058-9100
Practice Address - Country:US
Practice Address - Phone:501-908-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT98299183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician