Healthcare Provider Details

I. General information

NPI: 1477045003
Provider Name (Legal Business Name): JESSICA NICHOLE RATKOVIC CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W MAPLE AVE
SPRINGDALE AR
72764
US

IV. Provider business mailing address

601 W MAPLE AVE STE 503
SPRINGDALE AR
72764-5376
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-3722
  • Fax: 479-751-1099
Mailing address:
  • Phone: 479-751-3722
  • Fax: 479-751-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number24377
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC003237
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: