Healthcare Provider Details

I. General information

NPI: 1548443393
Provider Name (Legal Business Name): MARIE SANDUSKY RN, APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 S UNIVERSITY AVE DSC 102
LITTLE ROCK AR
72204-1000
US

IV. Provider business mailing address

2801 S UNIVERSITY AVE DSC 102
LITTLE ROCK AR
72204-1000
US

V. Phone/Fax

Practice location:
  • Phone: 501-569-3188
  • Fax: 501-683-7654
Mailing address:
  • Phone: 501-569-3188
  • Fax: 501-683-7654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR28118
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA01089 ANP
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: