Healthcare Provider Details

I. General information

NPI: 1750004644
Provider Name (Legal Business Name): ALEJANDRA JOSELIE AGUAYO RODRIGUEZ BACHELORS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEJANDRA JOSELINE AGUAYO RODRIGUEZ PLD

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SE 22ND ST STE 11
BENTONVILLE AR
72712-5180
US

IV. Provider business mailing address

1137 S SHERMAN AVE
FAYETTEVILLE AR
72701-1108
US

V. Phone/Fax

Practice location:
  • Phone: 479-289-8465
  • Fax:
Mailing address:
  • Phone: 479-249-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberPLD314
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: