Healthcare Provider Details

I. General information

NPI: 1205233152
Provider Name (Legal Business Name): STACY E CUNNINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 HWY 82 WEST
CROSSETT AR
71635
US

IV. Provider business mailing address

790 ROBERTS DRIVE
MONTICELLO AR
71655
US

V. Phone/Fax

Practice location:
  • Phone: 870-364-7248
  • Fax: 870-364-2249
Mailing address:
  • Phone: 870-367-9732
  • Fax: 870-460-6133

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: