Healthcare Provider Details

I. General information

NPI: 1114329497
Provider Name (Legal Business Name): TRAVIS WALLING APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 W MAIN ST
BOONEVILLE AR
72927-3420
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 479-675-4100
  • Fax: 479-675-4102
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA004204
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: