Healthcare Provider Details

I. General information

NPI: 1376276956
Provider Name (Legal Business Name): SAMANTHA MARIE MANKEY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 09/07/2023
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 HWY 62/412 STE J
ASH FLAT AR
72513-9629
US

IV. Provider business mailing address

1815 PLEASANT GROVE RD
JONESBORO AR
72405-7870
US

V. Phone/Fax

Practice location:
  • Phone: 870-994-7060
  • Fax: 870-994-7063
Mailing address:
  • Phone: 870-933-6886
  • Fax: 870-336-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: