Basic Information
| Provider Information | |||||||||
| NPI: | 1164006516 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAGG | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10301 MAYO DR | ||||||||
| Address2: | |||||||||
| City: | BARLING | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729231660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794945700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10301 MAYO DR | ||||||||
| Address2: | |||||||||
| City: | BARLING | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729231660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794945700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2021 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 215159 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.