Healthcare Provider Details

I. General information

NPI: 1679029227
Provider Name (Legal Business Name): NANCY PEMBERTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
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: 8-824-4094
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA004763
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: