Healthcare Provider Details

I. General information

NPI: 1104245745
Provider Name (Legal Business Name): SHANDA VINSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W 42ND AVE
PINE BLUFF AR
71603-7004
US

IV. Provider business mailing address

1120 GOGGANS RD
RISON AR
71665-8224
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA003867
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: