Healthcare Provider Details

I. General information

NPI: 1902126220
Provider Name (Legal Business Name): GENA MARIE DEAKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 EUPER LN
FORT SMITH AR
72903-3232
US

IV. Provider business mailing address

5400 EUPER LN
FORT SMITH AR
72903-3232
US

V. Phone/Fax

Practice location:
  • Phone: 479-755-6601
  • Fax:
Mailing address:
  • Phone: 479-755-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: