Healthcare Provider Details

I. General information

NPI: 1003509084
Provider Name (Legal Business Name): KATIE ANN HUTTO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 COX ST
BENTON AR
72015-4611
US

IV. Provider business mailing address

435 KETTLE RD
MALVERN AR
72104-7300
US

V. Phone/Fax

Practice location:
  • Phone: 501-776-0691
  • Fax:
Mailing address:
  • Phone: 501-425-1178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number124813
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: