1689838104 NPI number — MS. CANDACE MARIE CLARKE-BROWN AT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689838104 NPI number — MS. CANDACE MARIE CLARKE-BROWN AT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKE-BROWN
Provider First Name:
CANDACE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
AT
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:
1689838104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 SKYLINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72801-3362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-967-5570
Provider Business Mailing Address Fax Number:
479-890-5364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 SALEM RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72034-7525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-336-8300
Provider Business Practice Location Address Fax Number:
501-329-5508
Provider Enumeration Date:
07/14/2008

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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