Healthcare Provider Details

I. General information

NPI: 1952998221
Provider Name (Legal Business Name): CLARA LEE RENIA WHITE R.N. B.S.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 SHILOH DR
MABELVALE AR
72103-2141
US

IV. Provider business mailing address

6475 PIERCE MANSE LOOP
BENTON AR
72019-8541
US

V. Phone/Fax

Practice location:
  • Phone: 501-240-8771
  • Fax:
Mailing address:
  • Phone: 501-240-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR42861
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License NumberR42861
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR42861
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License NumberR42861
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR42861
License Number StateAR
# 6
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR42861
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: