Healthcare Provider Details

I. General information

NPI: 1669077152
Provider Name (Legal Business Name): MICHELLE ANNA DETKA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 GENE GEORGE BLVD
SPRINGDALE AR
72762-0845
US

IV. Provider business mailing address

2601 GENE GEORGE BLVD
SPRINGDALE AR
72762-0845
US

V. Phone/Fax

Practice location:
  • Phone: 479-725-6800
  • Fax: 479-725-6582
Mailing address:
  • Phone: 479-725-6800
  • Fax: 479-725-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPA-1450
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: