Healthcare Provider Details

I. General information

NPI: 1265102859
Provider Name (Legal Business Name): LAURA ANN HANNUM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 S WHITEHEAD DR
DE WITT AR
72042-2906
US

IV. Provider business mailing address

245 MADISON ST
CLARENDON AR
72029-2706
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-4505
  • Fax: 870-946-3357
Mailing address:
  • Phone: 870-747-8011
  • Fax: 870-747-3632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number125421
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: