Healthcare Provider Details

I. General information

NPI: 1225503691
Provider Name (Legal Business Name): JENNIFER DENISE BRALEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 N TYLER ST
LITTLE ROCK AR
72205-3535
US

IV. Provider business mailing address

3504 STOCKTON
BENTON AR
72019-2055
US

V. Phone/Fax

Practice location:
  • Phone: 501-664-2961
  • Fax: 501-664-6208
Mailing address:
  • Phone: 501-454-1795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR070416
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: