Healthcare Provider Details

I. General information

NPI: 1700373164
Provider Name (Legal Business Name): KIMBERLY SHARIECE MADDEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 W 12TH ST
LITTLE ROCK AR
72204-1513
US

IV. Provider business mailing address

6601 W 12TH ST
LITTLE ROCK AR
72204-1513
US

V. Phone/Fax

Practice location:
  • Phone: 501-666-8686
  • Fax:
Mailing address:
  • Phone: 501-666-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberR096140
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: