=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831838044
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER CRAIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2022
-----------------------------------------------------
Last Update Date | 07/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 SW KEYSTONE ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-5640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-283-0486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 SW KEYSTONE ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-5640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-283-0486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 220902
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------