Healthcare Provider Details

I. General information

NPI: 1124175773
Provider Name (Legal Business Name): SHANEYFELT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S. BALTIMORE
MANILA AR
72442-0630
US

IV. Provider business mailing address

PO BOX 630 105 SOUTH BALTIMORE STREET
MANILA AR
72442-0630
US

V. Phone/Fax

Practice location:
  • Phone: 870-561-4421
  • Fax: 870-561-3434
Mailing address:
  • Phone: 870-561-4421
  • Fax: 870-561-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. DORA ELIZABETH SHANEYFELT
Title or Position: OWNER AND ADVANCED PRACTICE NURSE
Credential: MSN, APN, CNS
Phone: 870-561-4421