Healthcare Provider Details

I. General information

NPI: 1639824956
Provider Name (Legal Business Name): THOMAS COLLIER HEAD APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HIGHWAY 62 W
SALEM AR
72576-8059
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-2015
  • Fax: 870-895-2164
Mailing address:
  • Phone: 870-856-1202
  • Fax: 866-500-4279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number218931
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: