Healthcare Provider Details

I. General information

NPI: 1518475466
Provider Name (Legal Business Name): VENITA LYNNE NINEMIRE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 NORTH MAIN ST
SALEM AR
72576
US

IV. Provider business mailing address

PO BOX 517
SALEM AR
72576-0517
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-2152
  • Fax:
Mailing address:
  • Phone: 870-895-6096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA005438
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA005438
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: