Healthcare Provider Details

I. General information

NPI: 1316557705
Provider Name (Legal Business Name): WANDA FAYE MOONEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WANDA FAYE ELLIS

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S BAY DR
BAY AR
72411-9482
US

IV. Provider business mailing address

4320 TRAILWATER DR
JONESBORO AR
72404-9194
US

V. Phone/Fax

Practice location:
  • Phone: 870-770-1920
  • Fax: 870-994-7488
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number125714
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: