Healthcare Provider Details

I. General information

NPI: 1356691703
Provider Name (Legal Business Name): DEBRA RENEE KIDD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 MCCAIN PARK DR
NORTH LITTLE ROCK AR
72116-7849
US

IV. Provider business mailing address

1700 MANDY CV
JACKSONVILLE AR
72076-2100
US

V. Phone/Fax

Practice location:
  • Phone: 501-916-9693
  • Fax: 501-916-9804
Mailing address:
  • Phone: 501-607-4870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR031850
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: