=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619860210
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENA ANN MCDONOUGH ACNPC-AG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2025
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9500 BAPTIST HEALTH DR STE 210
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-6343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-217-3533
-----------------------------------------------------
Fax | 501-217-3578
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2205 SHADOW RIDGE RD
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032-8779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-889-8496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 232025
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------