Healthcare Provider Details

I. General information

NPI: 1063487288
Provider Name (Legal Business Name): CREDONNA L MILLER AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MEDICAL PARK DR STE 101
BENTON AR
72015-3729
US

IV. Provider business mailing address

5 MEDICAL PARK DR STE 101
BENTON AR
72015-3729
US

V. Phone/Fax

Practice location:
  • Phone: 501-778-3868
  • Fax: 501-317-1704
Mailing address:
  • Phone: 501-778-3868
  • Fax: 501-317-1704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA#90
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: