Healthcare Provider Details

I. General information

NPI: 1235370891
Provider Name (Legal Business Name): NANCY PELLEGRINO STAM PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S WALDRON RD
FORT SMITH AR
72903-2556
US

IV. Provider business mailing address

PO BOX 23070
BARLING AR
72923-0070
US

V. Phone/Fax

Practice location:
  • Phone: 479-452-5040
  • Fax: 479-452-5047
Mailing address:
  • Phone: 479-452-5040
  • Fax: 479-452-5047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number048
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number148
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2010005264
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License NumberA004937
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: