Healthcare Provider Details

I. General information

NPI: 1093435869
Provider Name (Legal Business Name): KATIE STANDRIDGE CRUZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 COLLEGE AVE STE 200
CONWAY AR
72034-6297
US

IV. Provider business mailing address

PO BOX 9662
CONWAY AR
72033-9662
US

V. Phone/Fax

Practice location:
  • Phone: 501-513-5385
  • Fax: 501-513-5257
Mailing address:
  • Phone: 501-852-1363
  • Fax: 501-852-1364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number221187
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: