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General NPI Number Information
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NPI Number | 1770399305
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Entity Type | Organization
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Legal Business Name | WILD FIG, LLC
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Dates
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Enumeration Date | 12/09/2024
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Last Update Date | 12/09/2024
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Provider Practice Location Address
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Address Line | 215 N COLLEGE AVE
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City | FAYETTEVILLE
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State | AR
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Zip | 72701-4238
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Country | US
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Telephone | 479-301-5290
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 205
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City | BENTONVILLE
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State | AR
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Zip | 72712-0205
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Country | US
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Telephone | 618-554-8730
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Fax |
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Authorized Official
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Title or Position | OWNER/NURSE PRACTITIONER
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Name | CONNIE MARIE THOMAS
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Credential | DNP
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Telephone | 618-554-8730
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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