Healthcare Provider Details

I. General information

NPI: 1790610392
Provider Name (Legal Business Name): NICOLE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 N COLLEGE AVE
EL DORADO AR
71730-4403
US

IV. Provider business mailing address

1302 W 19TH ST
EL DORADO AR
71730-2934
US

V. Phone/Fax

Practice location:
  • Phone: 870-862-7921
  • Fax: 870-864-2490
Mailing address:
  • Phone:
  • Fax:

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: