Healthcare Provider Details

I. General information

NPI: 1639536956
Provider Name (Legal Business Name): ALLISON IVY RENFRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2016
Last Update Date: 01/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W 7TH ST
LITTLE ROCK AR
72205-5446
US

IV. Provider business mailing address

107 42ND PL APT D
NORTH LITTLE ROCK AR
72116-8115
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-1754
  • Fax: 501-257-1774
Mailing address:
  • Phone: 501-458-1036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRTP-018198
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: