Healthcare Provider Details

I. General information

NPI: 1508792896
Provider Name (Legal Business Name): DESTINY MARIE WOOLDRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 WHITNEY LN
KENSETT AR
72082-9028
US

IV. Provider business mailing address

1000 SWN DR
CONWAY AR
72032-2557
US

V. Phone/Fax

Practice location:
  • Phone: 501-389-2565
  • Fax:
Mailing address:
  • Phone: 501-328-3274
  • Fax: 501-328-3274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: