Healthcare Provider Details

I. General information

NPI: 1699802751
Provider Name (Legal Business Name): PAMELA LORRETTA LEE WHITTAKER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BALCOM LN
TRUMANN AR
72472-9502
US

IV. Provider business mailing address

162 COUNTY ROAD 409
JONESBORO AR
72404-8736
US

V. Phone/Fax

Practice location:
  • Phone: 870-483-1461
  • Fax:
Mailing address:
  • Phone: 870-935-0664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR76926
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: