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General NPI Number Information
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NPI Number | 1396551412
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Entity Type | Individual
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Provider Name | MALLORY RUTH WISDOM FNP-C
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Gender | Female
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 1233 W POPLAR ST
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City | ROGERS
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State | AR
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Zip | 72756-4245
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Country | US
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Telephone | 479-636-9235
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Fax | 479-751-2878
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Provider Business Mailing Address
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Address Line | 907 N 34TH ST
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City | ROGERS
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State | AR
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Zip | 72756-9151
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Country | US
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Telephone | 870-362-0914
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Fax |
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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 | 216033
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License Number State | AR
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