Basic Information
Provider Information | |||||||||
NPI: | 1023397304 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRISON | ||||||||
FirstName: | BRENDA | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 228 FIRE TOWER RD | ||||||||
Address2: |   | ||||||||
City: | BALD KNOB | ||||||||
State: | AR | ||||||||
PostalCode: | 720109739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5012830235 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3302 E MOORE AVE | ||||||||
Address2: |   | ||||||||
City: | SEARCY | ||||||||
State: | AR | ||||||||
PostalCode: | 721434886 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5012684181 | ||||||||
FaxNumber: | 5012685301 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2011 | ||||||||
LastUpdateDate: | 08/04/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | L44411 | AR | Y |   | Nursing Service Providers | Licensed Practical Nurse |   |
No ID Information.