Healthcare Provider Details

I. General information

NPI: 1104754654
Provider Name (Legal Business Name): KYLIE WIEDEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W ELM ST
CORNING AR
72422-2722
US

IV. Provider business mailing address

600 W ELM ST
CORNING AR
72422-2722
US

V. Phone/Fax

Practice location:
  • Phone: 870-926-5420
  • Fax: 870-634-2009
Mailing address:
  • Phone: 870-926-5420
  • Fax: 870-634-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: