1518782127 NPI number — DANA SUE MITCHUSSON RN

Table of content: DANA SUE MITCHUSSON RN (NPI 1518782127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518782127 NPI number — DANA SUE MITCHUSSON RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHUSSON
Provider First Name:
DANA
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENNINGS
Provider Other First Name:
DANA
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518782127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4504 PENNPOINTE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72076-3677
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-270-0955
Provider Business Mailing Address Fax Number:
866-716-1451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10800 FINANCIAL CENTRE PKWY STE 485
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72211-3539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-255-7375
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X , with the licence number:  R053340 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)