Healthcare Provider Details

I. General information

NPI: 1689550501
Provider Name (Legal Business Name): MELODIE PENN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 CHATEAU BLVD
PARAGOULD AR
72450-6264
US

IV. Provider business mailing address

1725 MEADOWLARK
POCAHONTAS AR
72455-1493
US

V. Phone/Fax

Practice location:
  • Phone: 501-725-0379
  • Fax:
Mailing address:
  • Phone: 870-378-2583
  • Fax: 870-378-2583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR3682
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: