Healthcare Provider Details

I. General information

NPI: 1366089740
Provider Name (Legal Business Name): KATELYN LAYNE WHITE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MEDICAL PARK DR STE 304
BENTON AR
72015-3745
US

IV. Provider business mailing address

5 MEDICAL PARK DR STE 304
BENTON AR
72015-3745
US

V. Phone/Fax

Practice location:
  • Phone: 501-776-6000
  • Fax:
Mailing address:
  • Phone: 501-776-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number122661
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: