Basic Information
| Provider Information | |||||||||
| NPI: | 1508178955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENDLEY | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | DARLENE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703472023 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 W SOUTH ST STE B | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720154235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018607150 | ||||||||
| FaxNumber: | 5018607166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2010 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A003402 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 185317758 | 05 | AR | MEDICAID |