Healthcare Provider Details

I. General information

NPI: 1134895170
Provider Name (Legal Business Name): CHARLENA DIAN BAGWELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 W KINGSHIGHWAY
PARAGOULD AR
72450-4164
US

IV. Provider business mailing address

1000 W KINGSHIGHWAY STE 14
PARAGOULD AR
72450-4197
US

V. Phone/Fax

Practice location:
  • Phone: 870-205-2000
  • Fax: 870-205-2001
Mailing address:
  • Phone: 870-239-8591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number213430
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: