Healthcare Provider Details

I. General information

NPI: 1891569182
Provider Name (Legal Business Name): DANIELLE D FARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 COLTON DR
FORT SMITH AR
72903-6352
US

IV. Provider business mailing address

4112 COLTON DR
FORT SMITH AR
72903-6352
US

V. Phone/Fax

Practice location:
  • Phone: 479-650-8066
  • Fax:
Mailing address:
  • Phone: 479-650-8066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: