Healthcare Provider Details

I. General information

NPI: 1528675386
Provider Name (Legal Business Name): KIMBERLY WALLER-JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 RICHARDS RD STE 4000
NORTH LITTLE ROCK AR
72117-2650
US

IV. Provider business mailing address

4000 RICHARDS RD STE A
NORTH LITTLE ROCK AR
72117-2939
US

V. Phone/Fax

Practice location:
  • Phone: 501-758-5133
  • Fax: 501-758-5173
Mailing address:
  • Phone: 501-758-5133
  • Fax: 501-758-5173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR082821
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number213192
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: