Healthcare Provider Details

I. General information

NPI: 1427607019
Provider Name (Legal Business Name): DESTINY BOUND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 N SALEM ROAD
FAYETTEVILLE AR
72704
US

IV. Provider business mailing address

3825 N SALEM ROAD
FAYETTEVILLE AR
72704
US

V. Phone/Fax

Practice location:
  • Phone: 479-409-5479
  • Fax:
Mailing address:
  • Phone: 479-409-5479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name: TERESA FEDOSKY
Title or Position: SENIOR MIDWIFE
Credential: CPM, LLM
Phone: 479-409-5479