Healthcare Provider Details

I. General information

NPI: 1700242211
Provider Name (Legal Business Name): MALISSA EPHLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1487 W KEISER AVE
OSCEOLA AR
72370-2806
US

IV. Provider business mailing address

1217 STONE ST
JONESBORO AR
72401-4520
US

V. Phone/Fax

Practice location:
  • Phone: 870-563-4500
  • Fax: 870-563-4501
Mailing address:
  • Phone: 870-972-1268
  • Fax: 870-934-0487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: