Healthcare Provider Details

I. General information

NPI: 1376368332
Provider Name (Legal Business Name): KENNETH CHINCHILLA PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S 2ND ST
CABOT AR
72023-2943
US

IV. Provider business mailing address

122 S 2ND ST
CABOT AR
72023-2943
US

V. Phone/Fax

Practice location:
  • Phone: 832-775-2018
  • Fax:
Mailing address:
  • Phone: 501-450-6350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number120399
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: