Healthcare Provider Details

I. General information

NPI: 1629256425
Provider Name (Legal Business Name): SANDRA K WOMACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 W DAISY L GATSON BATES DR
LITTLE ROCK AR
72202-5402
US

IV. Provider business mailing address

PO BOX 251970
LITTLE ROCK AR
72225-1970
US

V. Phone/Fax

Practice location:
  • Phone: 501-666-4949
  • Fax: 501-660-6840
Mailing address:
  • Phone: 501-666-8686
  • Fax: 501-660-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: