Healthcare Provider Details

I. General information

NPI: 1790411494
Provider Name (Legal Business Name): RIANNA NICODEMUS DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E COMMERCE ST STE B
MORRILTON AR
72110-2921
US

IV. Provider business mailing address

112 E COMMERCE ST STE B
MORRILTON AR
72110-2921
US

V. Phone/Fax

Practice location:
  • Phone: 501-289-1596
  • Fax: 501-313-0389
Mailing address:
  • Phone: 501-289-1596
  • Fax: 501-313-0389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number16353
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: