Individual
VISA LAHANG AVANCE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OTA
Contact information
Practice address
1656 W MATTHEWS AVE APT 5, JONESBORO, AR 72401-3311
(870) 995-4202
Mailing address
1656 W MATTHEWS AVE APT 5, JONESBORO, AR 72401-3311
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
OT-A545
AR
Other
Enumeration date
02/11/2009
Last updated
02/11/2009
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