Healthcare Provider Details

I. General information

NPI: 1396139903
Provider Name (Legal Business Name): AMBER LEE MAUTNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
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

1200 W WALNUT ST
ROGERS AR
72756-3521
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-7417
  • Fax: 479-751-4898
Mailing address:
  • Phone: 479-986-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberA004364
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: