Healthcare Provider Details

I. General information

NPI: 1740126069
Provider Name (Legal Business Name): ELIZABETH PUERTA CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 MAIN ST
MAMMOTH SPRING AR
72554-7466
US

IV. Provider business mailing address

PO BOX 7
MAMMOTH SPRING AR
72554-0007
US

V. Phone/Fax

Practice location:
  • Phone: 870-625-3222
  • Fax: 870-625-3216
Mailing address:
  • Phone: 870-625-3222
  • Fax: 870-625-3216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPT15743
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: