Healthcare Provider Details

I. General information

NPI: 1619247897
Provider Name (Legal Business Name): ALECIA TRENTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALECIA BRADSHAW

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 N BUSINESS DR STE 104
FAYETTEVILLE AR
72703-5287
US

IV. Provider business mailing address

2153 E JOYCE BLVD STE 201
FAYETTEVILLE AR
72703-5285
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-1532
  • Fax: 479-521-9940
Mailing address:
  • Phone: 479-575-9471
  • Fax: 479-587-9392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: