Basic Information
| Provider Information | |||||||||
| NPI: | 1053875146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727450550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794637775 | ||||||||
| FaxNumber: | 4794637187 | ||||||||
| Practice Location | |||||||||
| Address1: | 3215 N NORTH HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794637102 | ||||||||
| FaxNumber: | 4794635987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2019 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | R093463 | AR | N | Nursing Service Providers | Registered Nurse | Emergency | 363LF0000X | F01191795 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A006098 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 233547758 | 05 | AR | MEDICAID |