Healthcare Provider Details

I. General information

NPI: 1881502540
Provider Name (Legal Business Name): ALLIE ROSE GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 TATE AVE
MAMMOTH SPRING AR
72554-8064
US

IV. Provider business mailing address

198 GRASSE ST
CALICO ROCK AR
72519-8828
US

V. Phone/Fax

Practice location:
  • Phone: 870-625-0273
  • Fax: 870-625-0275
Mailing address:
  • Phone: 870-625-0273
  • Fax: 870-625-0275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: