Healthcare Provider Details

I. General information

NPI: 1265673735
Provider Name (Legal Business Name): JENNIFER LYNN DEPEW R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 W TRIMBLE AVE
BERRYVILLE AR
72616-4601
US

IV. Provider business mailing address

26748 DEER LN
SHELL KNOB MO
65747-8239
US

V. Phone/Fax

Practice location:
  • Phone: 870-423-2762
  • Fax: 870-423-2141
Mailing address:
  • Phone: 417-858-3606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR68969
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: