Healthcare Provider Details

I. General information

NPI: 1548033400
Provider Name (Legal Business Name): MANDOLIN GUNTER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 HIGHWAY 463 N
TRUMANN AR
72472-1636
US

IV. Provider business mailing address

831 HIGHWAY 463 N
TRUMANN AR
72472-1636
US

V. Phone/Fax

Practice location:
  • Phone: 870-418-0794
  • Fax:
Mailing address:
  • Phone: 870-418-0794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number218360
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: