=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215234836
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACI DIANN CLOUSE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2011
-----------------------------------------------------
Last Update Date | 02/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 SANTA FE DR
-----------------------------------------------------
City | SEARCY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72143-6964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-268-3853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 KEITH RD
-----------------------------------------------------
City | SEARCY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72143-9219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | P-T1107
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------