Provider Demographics
NPI:1356762900
Name:PEMBERTON, CARA LEE
Entity type:Individual
Prefix:
First Name:CARA
Middle Name:LEE
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARA
Other - Middle Name:LEE
Other - Last Name:PEMBERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1698 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-5965
Mailing Address - Country:US
Mailing Address - Phone:870-754-4602
Mailing Address - Fax:
Practice Address - Street 1:1698 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-5965
Practice Address - Country:US
Practice Address - Phone:870-754-4602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-29
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator