Healthcare Provider Details

I. General information

NPI: 1548693146
Provider Name (Legal Business Name): MRS. KAITLYN MARIE HOSTETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2206 N JACKSON
MAGNOLIA AR
71753-2065
US

IV. Provider business mailing address

502 E 12TH ST
SMACKOVER AR
71762-2123
US

V. Phone/Fax

Practice location:
  • Phone: 870-510-2841
  • Fax:
Mailing address:
  • Phone: 870-665-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number202498
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: