Healthcare Provider Details

I. General information

NPI: 1063778223
Provider Name (Legal Business Name): DEMETRIA ANN HURSEY MHPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEMETRIA FONDA MHPP

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 W MAIN ST
BLYTHEVILLE AR
72315-3336
US

IV. Provider business mailing address

634 W MAIN ST
BLYTHEVILLE AR
72315-3336
US

V. Phone/Fax

Practice location:
  • Phone: 870-780-6986
  • Fax: 870-741-6987
Mailing address:
  • Phone: 870-780-6986
  • Fax: 870-741-6987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: