Healthcare Provider Details

I. General information

NPI: 1821690884
Provider Name (Legal Business Name): MIKKA ELIZABETH FENLEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 06/17/2025
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 4TH ST
QUITMAN AR
72131-9289
US

IV. Provider business mailing address

PO BOX 1060
MARSHALL AR
72650-1060
US

V. Phone/Fax

Practice location:
  • Phone: 888-602-3647
  • Fax: 888-571-3256
Mailing address:
  • Phone: 501-358-6145
  • Fax: 501-504-6642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number213280
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: