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1497217418 NPI number — COURTNEY MAVIS WICKLIFFE OT

NPI Number: 1497217418
Health Care Provider/Practitioner: COURTNEY MAVIS WICKLIFFE OT

Information about “1497217418” NPI (COURTNEY MAVIS WICKLIFFE OT) exists in 1497217418 in HTML format HTML  |  1497217418 in plain Text format TXT  |  1497217418 in PDF (Portable Document Format) PDF  |  1497217418 in an XML format XML  formats.

NPI Number : 1497217418 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1497217418",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "WICKLIFFE",
    "FirstName": "COURTNEY",
    "MiddleName": "MAVIS",
    "NamePrefix": "MRS.",
    "NameSuffix": null,
    "Credential": "OT",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "2740 COLLEGE AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "CONWAY",
    "MailingAddressStateName": "AR",
    "MailingAddressPostalCode": "72034-6141",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "501-329-5459",
    "MailingAddressFaxNumber": "501-327-1738",
    "FirstLinePracticeLocationAddress": "1540 COUNTRY CLUB RD",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "SHERWOOD",
    "PracticeLocationAddressStateName": "AR",
    "PracticeLocationAddressPostalCode": "72120-5095",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "501-753-5459",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "04/01/2019",
    "LastUpdateDate": "05/22/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "225X00000X",
        "TaxonomyName": "Occupational Therapist",
        "LicenseNumber": "3276",
        "LicenseNumberStateCode": "AR",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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