Healthcare Provider Details

I. General information

NPI: 1578118873
Provider Name (Legal Business Name): ELIZABETH FAYE VALERIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W MAPLE AVE STE 205A
SPRINGDALE AR
72764-5336
US

IV. Provider business mailing address

601 W MAPLE AVE STE 205A
SPRINGDALE AR
72764-5336
US

V. Phone/Fax

Practice location:
  • Phone: 479-326-9400
  • Fax: 479-309-9693
Mailing address:
  • Phone: 479-326-9400
  • Fax: 479-309-9693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: