Healthcare Provider Details

I. General information

NPI: 1528560513
Provider Name (Legal Business Name): RICKEY EDNA MACK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 N FOURCHE AVE
PERRYVILLE AR
72126-8545
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 501-238-1284
  • Fax: 501-679-8970
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA005560
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: