Provider Demographics
NPI:1801455829
Name:COMBS, LAUREN ELLIS (BS)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:ELLIS
Last Name:COMBS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-4081
Mailing Address - Country:US
Mailing Address - Phone:417-543-1501
Mailing Address - Fax:
Practice Address - Street 1:301 W TRIMBLE AVE
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-3112
Practice Address - Country:US
Practice Address - Phone:870-423-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200612Medicaid