Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | OT-A1255 | AR |
NPI | 1013554963 |
---|---|
Provider Name | Taylor Vongphakdy |
First Address | Farmington, AR 72730-8678 |
Second Address | Farmington, AR 72730-8678 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/12/2019 |
Last Update Date | 10/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
OT-A1255 | STATE LICENSE NUMBER (01) | AR |