Provider Demographics
NPI:1396426821
Name:FUNDERBURG, ANNA MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:MARIE
Last Name:FUNDERBURG
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 1:1069 FLORENCE RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-4497
Mailing Address - Country:US
Mailing Address - Phone:870-224-6219
Mailing Address - Fax:
Practice Address - Street 1:206 BRAGG ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-2500
Practice Address - Country:US
Practice Address - Phone:870-226-7844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4807225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant