MEDICARE: STEPHANIE L BOHANNON PMHNP, APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	124030	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104459114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE L BOHANNON PMHNP, APRN

Provider Business Mailing Address
First Line	:	2566 E JOYCE BLVD STE 2
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-3923
Country	:	US
Telephone Number	:	479-935-1000
Fax Number	:	417-350-1935

Provider Business Practice Location Address
First Line	:	2566 E JOYCE BLVD STE 2
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-3923
Country	:	US
Telephone Number	:	479-935-1000
Fax Number	:	479-935-9200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2020
Last Update Date	:	09/21/2022

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