Healthcare Provider Details

I. General information

NPI: 1114484417
Provider Name (Legal Business Name): ALEX ELAINE MATLOCK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 SHACKLEFORD DR
LITTLE ROCK AR
72211-2858
US

IV. Provider business mailing address

6 SHACKLEFORD DR
LITTLE ROCK AR
72211-2858
US

V. Phone/Fax

Practice location:
  • Phone: 501-500-5001
  • Fax:
Mailing address:
  • Phone: 501-500-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA006101
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: