Healthcare Provider Details

I. General information

NPI: 1316147911
Provider Name (Legal Business Name): LARA CHRISTINE BULKLEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 WINDOVER RD
JONESBORO AR
72401-6007
US

IV. Provider business mailing address

107 CYPRESS PT
PARAGOULD AR
72450-7104
US

V. Phone/Fax

Practice location:
  • Phone: 870-935-0861
  • Fax: 870-972-5241
Mailing address:
  • Phone: 870-476-0850
  • Fax: 870-240-8028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number077543
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: