Healthcare Provider Details

I. General information

NPI: 1265058804
Provider Name (Legal Business Name): STEPHANIE ANN MOSER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 RED BUD DR
SOUTHSIDE AR
72501-8049
US

IV. Provider business mailing address

36 RED BUD DR
SOUTHSIDE AR
72501-8049
US

V. Phone/Fax

Practice location:
  • Phone: 879-262-9302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number125283
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: