Basic Information
| Provider Information | |||||||||
| NPI: | 1295192847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDBRINK | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7001 ROGERS AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793144650 | ||||||||
| FaxNumber: | 4794529459 | ||||||||
| Practice Location | |||||||||
| Address1: | 7001 ROGERS AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793144650 | ||||||||
| FaxNumber: | 4794529459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 09/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A004619 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | A004619 | 01 | AR | STATE LICENSE | OTHER | PENDING | 05 | AR | MEDICAID |