Healthcare Provider Details

I. General information

NPI: 1467707166
Provider Name (Legal Business Name): STACEY KIRK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 EAST CENTERTON BLVD.
CENTERTON AR
72719
US

IV. Provider business mailing address

2153 E. JOYCE BLVD,
FAYETTEVILLE AR
72703-5285
US

V. Phone/Fax

Practice location:
  • Phone: 479-795-1802
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: