Healthcare Provider Details

I. General information

NPI: 1336417997
Provider Name (Legal Business Name): SUSAN LEA ZICKLER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E CRANDALL AVE
HARRISON AR
72601-3629
US

IV. Provider business mailing address

1204 SE 28TH ST SUITE 2
BENTONVILLE AR
72712-3881
US

V. Phone/Fax

Practice location:
  • Phone: 870-204-6126
  • Fax: 870-204-6264
Mailing address:
  • Phone: 479-464-8834
  • Fax: 479-464-8838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03627
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: