Provider Demographics
NPI:1053971622
Name:STUDDARD, ELIZABETH BACON (MAT, ATC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BACON
Last Name:STUDDARD
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Gender:F
Credentials:MAT, ATC
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1671 S COLONNADE DR APT 203
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-7819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1671 S COLONNADE DR APT 203
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-7819
Practice Address - Country:US
Practice Address - Phone:205-746-5362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer