Healthcare Provider Details

I. General information

NPI: 1255341608
Provider Name (Legal Business Name): DOROTHY FENWICK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 SKYLINE DR
VAN BUREN AR
72956-2547
US

IV. Provider business mailing address

907 SKYLINE DR
VAN BUREN AR
72956-2547
US

V. Phone/Fax

Practice location:
  • Phone: 479-650-4314
  • Fax: 479-474-8457
Mailing address:
  • Phone: 479-650-4314
  • Fax: 479-474-8457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0074442 D856337
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: