Healthcare Provider Details

I. General information

NPI: 1629408497
Provider Name (Legal Business Name): SHERILYN JO BENNETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 W 6TH ST
WALDRON AR
72958-7642
US

IV. Provider business mailing address

1683 JENKINS RD PO BOX 2031
WALDRON AR
72958-8061
US

V. Phone/Fax

Practice location:
  • Phone: 479-637-1181
  • Fax:
Mailing address:
  • Phone: 479-637-1181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR86370
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA003998
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: