=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275173544
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANA HEADLEY APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2020
-----------------------------------------------------
Last Update Date | 01/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 N ILLINOIS ST
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72432-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-578-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 144
-----------------------------------------------------
City | VANNDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72387-0144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-362-9028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 122100
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------