Healthcare Provider Details

I. General information

NPI: 1316524598
Provider Name (Legal Business Name): SHANA CUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 SE LINDSEY ST
HOXIE AR
72433-2224
US

IV. Provider business mailing address

PO BOX 299
HOXIE AR
72433-0299
US

V. Phone/Fax

Practice location:
  • Phone: 870-886-1333
  • Fax: 870-886-1334
Mailing address:
  • Phone: 870-886-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: