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General NPI Number Information
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NPI Number | 1275932253
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Entity Type | Individual
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Provider Name | MONIQUE THAMMAVONG APRN, NP-C
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Gender | Female
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Dates
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Enumeration Date | 08/15/2014
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Last Update Date | 10/11/2023
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Provider Practice Location Address
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Address Line | 209 POINTER TRL W STE A
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City | VAN BUREN
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State | AR
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Zip | 72956-2238
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Country | US
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Telephone | 479-474-1100
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Fax | 479-471-1335
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Provider Business Mailing Address
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Address Line | 11001 EXECUTIVE CENTER DR STE 200
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City | LITTLE ROCK
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State | AR
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Zip | 72211-4393
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Country | US
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Telephone | 479-474-1100
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Fax | 479-471-1335
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | A004175
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License Number State | AR
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