Healthcare Provider Details

I. General information

NPI: 1104225317
Provider Name (Legal Business Name): JOANN MAHAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3416 OLD GREENWOOD RD
FORT SMITH AR
72903-5462
US

IV. Provider business mailing address

3416 OLD GREENWOOD RD
FORT SMITH AR
72903-5462
US

V. Phone/Fax

Practice location:
  • Phone: 479-242-2888
  • Fax: 479-242-2889
Mailing address:
  • Phone: 479-242-2888
  • Fax: 479-242-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004261
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR43284
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: