Healthcare Provider Details

I. General information

NPI: 1588297972
Provider Name (Legal Business Name): WAKETTA LASHELLE ALDRIDGE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2816 FOX MEADOW LN
JONESBORO AR
72404-9346
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 870-336-1675
  • Fax: 870-336-1679
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-301-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number122838
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: