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General NPI Number Information
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NPI Number | 1407515141
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Entity Type | Organization
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Legal Business Name | DEFY AGE MED SPA, PLLC
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Dates
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Enumeration Date | 12/09/2021
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Last Update Date | 12/09/2021
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Provider Practice Location Address
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Address Line | 2501 DAVE WARD DR STE A17
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City | CONWAY
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State | AR
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Zip | 72034-6090
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Country | US
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Telephone | 501-499-9252
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Fax |
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Provider Business Mailing Address
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Address Line | 2501 DAVE WARD DR STE A17
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City | CONWAY
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State | AR
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Zip | 72034-6090
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Country | US
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Telephone | 501-499-9252
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | HEATHER WHALEY
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Credential | MD
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Telephone | 501-554-6005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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