Provider Demographics
NPI:1215097050
Name:DURHAM, ELLA BETH (CPO, CPED)
Entity type:Individual
Prefix:MS
First Name:ELLA
Middle Name:BETH
Last Name:DURHAM
Suffix:
Gender:F
Credentials:CPO, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 E MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4831
Mailing Address - Country:US
Mailing Address - Phone:501-368-0868
Mailing Address - Fax:501-368-0003
Practice Address - Street 1:2930 E MOORE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4831
Practice Address - Country:US
Practice Address - Phone:501-368-0868
Practice Address - Fax:501-368-0003
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR457554716Medicaid
AR5371100001Medicare NSC