Provider Demographics
NPI:1700455516
Name:MARSOLAN, LAURA BLAIRE (ECDS)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BLAIRE
Last Name:MARSOLAN
Suffix:
Gender:F
Credentials:ECDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 APACHE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7404
Mailing Address - Country:US
Mailing Address - Phone:870-333-5437
Mailing Address - Fax:870-333-5237
Practice Address - Street 1:3100 APACHE DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7404
Practice Address - Country:US
Practice Address - Phone:870-333-5437
Practice Address - Fax:870-333-5237
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1164957080Medicaid