Provider Demographics
NPI:1083447437
Name:LEAVY, LAZORA LYNETTE
Entity type:Individual
Prefix:
First Name:LAZORA
Middle Name:LYNETTE
Last Name:LEAVY
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 1:900 SHALL CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-2422
Mailing Address - Country:US
Mailing Address - Phone:501-680-7499
Mailing Address - Fax:
Practice Address - Street 1:900 SHALL CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-2422
Practice Address - Country:US
Practice Address - Phone:501-680-7499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2125343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)