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General NPI Number Information
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NPI Number | 1669386876
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Entity Type | Organization
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Legal Business Name | DIABETES & KIDNEY DISEASE PREVENTION PROGRAM, LLC
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Dates
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Enumeration Date | 10/02/2026
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Last Update Date | 10/02/2026
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Provider Practice Location Address
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Address Line | 1007 FAIRWAY DR
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City | PINE BLUFF
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State | AR
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Zip | 71603-8105
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Country | US
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Telephone | 870-718-6329
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Fax |
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Provider Business Mailing Address
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Address Line | 1007 FAIRWAY DR
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City | PINE BLUFF
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State | AR
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Zip | 71603-8105
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Country | US
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Telephone | 870-718-6329
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR, LIFESTYLE COACH
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Name | NICOLE DANISE BATES
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Credential | FNP-BC
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Telephone | 870-718-6329
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State | NULL
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