Basic Information
| Provider Information | |||||||||
| NPI: | 1316557705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOONEY | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | FAYE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLIS | ||||||||
| OtherFirstName: | WANDA | ||||||||
| OtherMiddleName: | FAYE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4196 HIGHWAY 62 412 STE A | ||||||||
| Address2: | |||||||||
| City: | HARDY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725428002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8708562107 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S BAY DR | ||||||||
| Address2: | |||||||||
| City: | BAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724119482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707701920 | ||||||||
| FaxNumber: | 8709947488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2020 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 125714 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.