Healthcare Provider Details

I. General information

NPI: 1205345386
Provider Name (Legal Business Name): BLAKELY REEDER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 NORTHSHORE DR
N LITTLE ROCK AR
72118-5312
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 877-918-7020
  • Fax: 479-968-1673
Mailing address:
  • Phone: 866-601-8435
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA005358
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: