Healthcare Provider Details

I. General information

NPI: 1114249976
Provider Name (Legal Business Name): MRS. BRANDY NICHOLE TINSLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 LILY DR
MAUMELLE AR
72113-5828
US

IV. Provider business mailing address

164 LILY DR
MAUMELLE AR
72113-5828
US

V. Phone/Fax

Practice location:
  • Phone: 501-202-2685
  • Fax: 501-202-2003
Mailing address:
  • Phone: 501-202-2685
  • Fax: 501-202-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1888
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: