Healthcare Provider Details

I. General information

NPI: 1861015851
Provider Name (Legal Business Name): BAILEY NOEL BASTIEN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 IRBY DR APT 4108
CONWAY AR
72034-7765
US

IV. Provider business mailing address

3100 IRBY DR APT 4108
CONWAY AR
72034-7765
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: