Healthcare Provider Details

I. General information

NPI: 1003505389
Provider Name (Legal Business Name): SKIN DERMATOLOGY PRACTITIONER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3106 SOUTHWEST DR STE 103
JONESBORO AR
72404-8404
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 870-641-7546
  • Fax: 870-641-7547
Mailing address:
  • Phone: 800-824-4094
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NANCY PEMBERTON
Title or Position: AUTHORIZED OFFICIAL
Credential: NP
Phone: 708-530-2453