Healthcare Provider Details

I. General information

NPI: 1558562694
Provider Name (Legal Business Name): MONICA NICOLE WILBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6263 HIGHWAY 49 S
PARAGOULD AR
72450-2004
US

IV. Provider business mailing address

605 DOGWOOD VIEW DR
PARAGOULD AR
72450-3702
US

V. Phone/Fax

Practice location:
  • Phone: 870-240-0444
  • Fax: 870-240-0466
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: