Healthcare Provider Details

I. General information

NPI: 1508269051
Provider Name (Legal Business Name): LEDONNA GILMER NURSE EXTENDER/RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 SHAKE RAG RD
CLINTON AR
72031-6629
US

IV. Provider business mailing address

PO BOX 1589
BENTON AR
72018-1589
US

V. Phone/Fax

Practice location:
  • Phone: 501-745-6644
  • Fax:
Mailing address:
  • Phone: 501-315-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR072310
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: