Healthcare Provider Details

I. General information

NPI: 1053816827
Provider Name (Legal Business Name): PEGGIE TISDALE-BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. PEGGIE TISDALE BROWN

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1864 E PARKSHORE DR APT 11
FAYETTEVILLE AR
72703-6268
US

IV. Provider business mailing address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1944
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-4301
  • Fax: 479-587-5994
Mailing address:
  • Phone: 479-443-4301
  • Fax: 479-587-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8100-M
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: