=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396117453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEGGY DARTY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2015
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 MEDICAL DR
-----------------------------------------------------
City | BLYTHEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72315-1425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-563-6504
-----------------------------------------------------
Fax | 870-563-7482
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 E CHERYL ST
-----------------------------------------------------
City | OSCEOLA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72370-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-563-6504
-----------------------------------------------------
Fax | 870-563-7482
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | A004519
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------