Healthcare Provider Details

I. General information

NPI: 1679384549
Provider Name (Legal Business Name): TIFFANY RHETT DICKINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 N BLUE STAR DR
FAYETTEVILLE AR
72703-3678
US

IV. Provider business mailing address

PO BOX 8162
FAYETTEVILLE AR
72703-0003
US

V. Phone/Fax

Practice location:
  • Phone: 479-283-2871
  • Fax:
Mailing address:
  • Phone: 479-283-2871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number230351
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR078489
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR078489
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License NumberR078489
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: