Healthcare Provider Details

I. General information

NPI: 1164246278
Provider Name (Legal Business Name): MARY OMBATSA BANKS PMHMP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W CAPITOL AVE STE 1700
LITTLE ROCK AR
72201-3421
US

IV. Provider business mailing address

13008 AVILLA HILLS CV
ALEXANDER AR
72002-8074
US

V. Phone/Fax

Practice location:
  • Phone: 501-353-7110
  • Fax:
Mailing address:
  • Phone: 501-353-7110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number232176
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: