Healthcare Provider Details

I. General information

NPI: 1578860094
Provider Name (Legal Business Name): SYDNEY G. REPHAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 783
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4301 W MARKHAM ST # 783
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-8051
  • Fax: 501-686-8421
Mailing address:
  • Phone: 501-686-8051
  • Fax: 501-686-8421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number573
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: