Healthcare Provider Details

I. General information

NPI: 1720716707
Provider Name (Legal Business Name): CLAYTON ALLSTUN BAILEY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 W TRUCKERS DR
FAYETTEVILLE AR
72704-5637
US

IV. Provider business mailing address

2711 E LINWOOD ST
SPRINGFIELD MO
65804-1936
US

V. Phone/Fax

Practice location:
  • Phone: 479-973-6000
  • Fax:
Mailing address:
  • Phone: 417-425-4327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2012033480
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number221606
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: