Healthcare Provider Details

I. General information

NPI: 1720514847
Provider Name (Legal Business Name): SASHA LAINE KUTZ APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. SASHA LAINE FOSSETT

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1678 KENSINGTON PL
SPRINGDALE AR
72764-1159
US

IV. Provider business mailing address

1678 KENSINGTON PL
SPRINGDALE AR
72764-1159
US

V. Phone/Fax

Practice location:
  • Phone: 479-799-7515
  • Fax:
Mailing address:
  • Phone: 479-799-7515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA005127
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: