Healthcare Provider Details

I. General information

NPI: 1942866652
Provider Name (Legal Business Name): AMANDA PENNINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 E CHURCH ST
WARREN AR
71671
US

IV. Provider business mailing address

790 ROBERTS DR
MONTICELLO AR
71655-5723
US

V. Phone/Fax

Practice location:
  • Phone: 870-226-5856
  • Fax:
Mailing address:
  • Phone: 870-367-2461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: