Provider Demographics
NPI:1104919612
Name:PAULEY, AMBER MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:MICHELLE
Last Name:PAULEY
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 1:311 EVANS DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730
Mailing Address - Country:US
Mailing Address - Phone:870-862-6989
Mailing Address - Fax:
Practice Address - Street 1:431 W OAK ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4566
Practice Address - Country:US
Practice Address - Phone:870-864-9190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2085174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159237721Medicaid