MEDICARE: MS. LATOYA DANIELLE YOUNG 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	363LG0600X	Gerontology Nurse Practitioner	120746	AR

General Provider Information

NPI Number	:	1154964559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LATOYA DANIELLE YOUNG APRN

Provider Business Mailing Address
First Line	:	11001 EXECUTIVE CENTER DR STE 200
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-4393
Country	:	US
Telephone Number	:	501-435-3325
Fax Number	:	501-435-3330

Provider Business Practice Location Address
First Line	:	4635 JOHN F KENNEDY BLVD
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7310
Country	:	US
Telephone Number	:	501-435-3325
Fax Number	:	501-435-3330

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

Provider Enumeration Date	:	10/18/2019
Last Update Date	:	01/28/2022

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