Healthcare Provider Details

I. General information

NPI: 1578198594
Provider Name (Legal Business Name): ANNI JULLIETT FUENMAYOR MS, PLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 COLLEGE AVE
CONWAY AR
72034-6297
US

IV. Provider business mailing address

2302 COLLEGE AVE
CONWAY AR
72034-6297
US

V. Phone/Fax

Practice location:
  • Phone: 501-513-5135
  • Fax:
Mailing address:
  • Phone: 501-513-5135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberPLD237
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberPLD237
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: