=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134528581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL NELLUMS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2014
-----------------------------------------------------
Last Update Date | 06/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 S LAUREL ST
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71601-4859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-534-4900
-----------------------------------------------------
Fax | 870-534-4906
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 S LAUREL ST
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71601-4859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-534-4900
-----------------------------------------------------
Fax | 870-534-4906
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | L042487
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------