Healthcare Provider Details

I. General information

NPI: 1891544888
Provider Name (Legal Business Name): MICHELLE VANBLARICOM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 E EMMA AVE STE 300
SPRINGDALE AR
72764-4469
US

IV. Provider business mailing address

2902 DRIFTWOOD LN
ROGERS AR
72756-1729
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-7417
  • Fax: 479-751-2878
Mailing address:
  • Phone: 870-480-9953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0300X
TaxonomyNephrology Registered Nurse
License NumberR096821
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number228738
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: