Healthcare Provider Details

I. General information

NPI: 1902689458
Provider Name (Legal Business Name): EMILEE VERGARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 1ST ST STE 4
JACKSONVILLE AR
72076-4139
US

IV. Provider business mailing address

1200 COVINGTON WAY APT 1009
CONWAY AR
72034-7165
US

V. Phone/Fax

Practice location:
  • Phone: 501-241-0410
  • Fax:
Mailing address:
  • Phone: 817-602-9957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: