Healthcare Provider Details

I. General information

NPI: 1265217236
Provider Name (Legal Business Name): NIKKI I PASTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 W SUNBRIDGE DR
FAYETTEVILLE AR
72703-1822
US

IV. Provider business mailing address

74 W SUNBRIDGE DR
FAYETTEVILLE AR
72703-1822
US

V. Phone/Fax

Practice location:
  • Phone: 479-582-5565
  • Fax: 479-582-5574
Mailing address:
  • Phone: 479-582-5565
  • Fax: 479-582-5574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2603013
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: