Healthcare Provider Details

I. General information

NPI: 1225679558
Provider Name (Legal Business Name): CHARITY ANGELA LANE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 WEST STATE ST
CARAWAY AR
72419-8553
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 870-956-0200
  • Fax: 870-895-2164
Mailing address:
  • Phone: 870-856-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1054179
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26264
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number121536
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1054179
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: