MEDICARE: MS. TANECIA NICOLA STANLEY

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	104100000X	Social Worker	933811772	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14316291	OTHER	AR	UMR

General Provider Information

NPI Number	:	1558942680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TANECIA NICOLA STANLEY

Provider Business Mailing Address
First Line	:	305 S PALM ST
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-5432
Country	:	US
Telephone Number	:	501-686-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 FOX DEN CT
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72118-3063
Country	:	US
Telephone Number	:	501-240-3823
Fax Number	:

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

Provider Enumeration Date	:	04/20/2021
Last Update Date	:	04/20/2021

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