Healthcare Provider Details

I. General information

NPI: 1992464846
Provider Name (Legal Business Name): BRENDA KORDIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 OVERTON DR
BELLA VISTA AR
72714-1723
US

IV. Provider business mailing address

6035 W TRANSIT ST
FAYETTEVILLE AR
72704-5097
US

V. Phone/Fax

Practice location:
  • Phone: 425-281-3385
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number216778
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: