Healthcare Provider Details

I. General information

NPI: 1194423327
Provider Name (Legal Business Name): CANDICE M KILLEEN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 S 1ST ST STE 203
ROGERS AR
72756-4504
US

IV. Provider business mailing address

10748 W HIGH MEADOWS DR
ROGERS AR
72756-8953
US

V. Phone/Fax

Practice location:
  • Phone: 479-935-3322
  • Fax:
Mailing address:
  • Phone: 479-595-5484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number219646
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: