Healthcare Provider Details

I. General information

NPI: 1184825408
Provider Name (Legal Business Name): APN RAINBOW PEDIATRIC SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5507 WALSH LANE STE 101
ROGERS AR
72758-8941
US

IV. Provider business mailing address

5507 WALSH LANE STE 101
ROGERS AR
72758-8941
US

V. Phone/Fax

Practice location:
  • Phone: 479-464-8231
  • Fax: 479-464-8230
Mailing address:
  • Phone: 479-464-8231
  • Fax: 479-464-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA01589
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateAR

VIII. Authorized Official

Name: MARILOU SHREVE-DOFFIN
Title or Position: OWNER
Credential: APN
Phone: 479-464-8231