Healthcare Provider Details

I. General information

NPI: 1174569602
Provider Name (Legal Business Name): TERRENCE CHRISTOPHER DIEBOLD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 PRESTWICK CIR
JONESBORO AR
72401-8039
US

IV. Provider business mailing address

3120 PRESTWICK CIR
JONESBORO AR
72401-8039
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-0281
  • Fax: 870-972-8694
Mailing address:
  • Phone: 870-972-0281
  • Fax: 870-972-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: