Healthcare Provider Details

I. General information

NPI: 1790939064
Provider Name (Legal Business Name): JULIE A IRONSIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 LATHAM DR
LOWELL AR
72745-8360
US

IV. Provider business mailing address

800 MARSHALL ST SLOT 900
LITTLE ROCK AR
72202-3510
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-0130
  • Fax: 479-750-0937
Mailing address:
  • Phone: 501-364-3620
  • Fax: 501-362-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR24456
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: