Healthcare Provider Details

I. General information

NPI: 1033847975
Provider Name (Legal Business Name): GRACEN LEE DALE MSN, APRN, NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACEN LEE FELTY

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY # 211
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

602 OLD HIGHWAY 11 S
HAZEN AR
72064-9659
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1244
  • Fax:
Mailing address:
  • Phone: 870-255-5044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number221005
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: