Healthcare Provider Details

I. General information

NPI: 1679486500
Provider Name (Legal Business Name): SANTOSHA LATREESE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E WASHINGTON AVE
JONESBORO AR
72401-3111
US

IV. Provider business mailing address

408 WIREGRASS WAY
JONESBORO AR
72405-9422
US

V. Phone/Fax

Practice location:
  • Phone: 870-207-4100
  • Fax:
Mailing address:
  • Phone: 870-351-0102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number239641
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: