Healthcare Provider Details

I. General information

NPI: 1699795252
Provider Name (Legal Business Name): MARILYN MARY SOSSAMON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1658 HWY 371 WEST
PRESCOTT AR
71857
US

IV. Provider business mailing address

2904 ARKANSAS BLVD
TEXARKANA AR
71854-2536
US

V. Phone/Fax

Practice location:
  • Phone: 870-887-3660
  • Fax: 870-887-3705
Mailing address:
  • Phone: 870-773-4655
  • Fax: 870-772-4650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL25376
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: