Provider Demographics
NPI:1386142982
Name:GOINES, HAZEL LEANN
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:LEANN
Last Name:GOINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-6073
Mailing Address - Country:US
Mailing Address - Phone:479-410-1900
Mailing Address - Fax:479-410-1063
Practice Address - Street 1:2502 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-6073
Practice Address - Country:US
Practice Address - Phone:479-410-1900
Practice Address - Fax:479-410-1063
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1275225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140658721Medicaid