Healthcare Provider Details

I. General information

NPI: 1962811562
Provider Name (Legal Business Name): KRISTINA KOON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 DONAGHEY AVE
CONWAY AR
72032-2511
US

IV. Provider business mailing address

110 SKYLINE DR
RUSSELLVILLE AR
72801-3362
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-1701
  • Fax: 501-327-3234
Mailing address:
  • Phone: 479-968-1298
  • Fax: 479-968-6053

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: