1326392671 NPI number — LAKISHA A MCDANIEL FNP

Table of content: KRISTINA ROMANCZUK PHDH (NPI 1467211565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326392671 NPI number — LAKISHA A MCDANIEL FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDANIEL
Provider First Name:
LAKISHA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326392671
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 W KEISER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSCEOLA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72370-3506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-563-6512
Provider Business Mailing Address Fax Number:
870-563-5013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 ARKANSAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EARLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72331-2217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-792-7676
Provider Business Practice Location Address Fax Number:
870-792-7676
Provider Enumeration Date:
11/07/2012

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: 363LF0000X , with the licence number:  17083 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: A003767 , 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)

  • Identifier: 17083 . This is a "FAMILY NURSE PRACTITIONER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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