Healthcare Provider Details

I. General information

NPI: 1386895100
Provider Name (Legal Business Name): DIVINE INTERVENTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425-A N. CENTENNIAL
WEST FORK AR
72774-1006
US

IV. Provider business mailing address

PO BOX 1006
WEST FORK AR
72774-1006
US

V. Phone/Fax

Practice location:
  • Phone: 479-839-2670
  • Fax: 479-294-6067
Mailing address:
  • Phone: 479-839-2670
  • Fax: 479-294-6067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberA02935
License Number StateAR

VIII. Authorized Official

Name: SANDY M BRANSON
Title or Position: MANAGER
Credential: APN
Phone: 479-839-2670