Basic Information
| Provider Information | |||||||||
| NPI: | 1356691703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIDD | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 MANDY CV | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720762100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016074870 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3901 MCCAIN PARK DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721167849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019169693 | ||||||||
| FaxNumber: | 5019169804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R031850 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
No ID Information.