Healthcare Provider Details

I. General information

NPI: 1053244517
Provider Name (Legal Business Name): FUNCTIONAL HEADACHE AND WELLNESS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 LAWRENCE ROAD 1315
BLACK ROCK AR
72415-9158
US

IV. Provider business mailing address

79 LAWRENCE ROAD 1315
BLACK ROCK AR
72415-9158
US

V. Phone/Fax

Practice location:
  • Phone: 870-878-2188
  • Fax:
Mailing address:
  • Phone: 870-878-2188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMY FREEMAN
Title or Position: OWNER
Credential: APRN
Phone: 870-878-2188