Healthcare Provider Details

I. General information

NPI: 1093336323
Provider Name (Legal Business Name): NICHOLAS LEE HAYWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 HIGHWAY 367 S
TUCKERMAN AR
72473-9148
US

IV. Provider business mailing address

809 ELIZABETH LN
JONESBORO AR
72405-9412
US

V. Phone/Fax

Practice location:
  • Phone: 870-808-4040
  • Fax: 870-277-0896
Mailing address:
  • Phone: 870-598-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5894
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: