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General NPI Number Information
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NPI Number | 1003505389
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Entity Type | Organization
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Legal Business Name | SKIN DERMATOLOGY PRACTITIONER, PLLC
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Dates
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Enumeration Date | 05/03/2023
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Last Update Date | 06/21/2023
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Provider Practice Location Address
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Address Line | 3106 SOUTHWEST DR STE 103
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City | JONESBORO
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State | AR
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Zip | 72404-8404
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Country | US
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Telephone | 870-641-7546
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Fax | 870-641-7547
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Provider Business Mailing Address
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Address Line | PO BOX 9178
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City | RUSSELLVILLE
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State | AR
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Zip | 72811-9178
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Country | US
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Telephone | 800-824-4094
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Fax | 479-968-1673
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | NANCY PEMBERTON
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Credential | NP
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Telephone | 708-530-2453
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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