Basic Information
| Provider Information | |||||||||
| NPI: | 1790823748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | VONDA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MCD, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5205 KOALA DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724048836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708022670 | ||||||||
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| Practice Location | |||||||||
| Address1: | 806 GLENDALE ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724014455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709339528 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP#1959 | AR | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 5W899 | 05 | AR | MEDICAID | 146701724 | 01 | AR | AR BLUE CROSS BLUE SHIELD | OTHER |