Healthcare Provider Details

I. General information

NPI: 1225751076
Provider Name (Legal Business Name): ANGELA EUNICE CLEOFE MERCADO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 TOWSON AVE
FORT SMITH AR
72901-4921
US

IV. Provider business mailing address

3502 S N ST APT A
FORT SMITH AR
72903-0536
US

V. Phone/Fax

Practice location:
  • Phone: 479-441-4000
  • Fax:
Mailing address:
  • Phone: 662-715-7087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number218195
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: