Basic Information
| Provider Information | |||||||||
| NPI: | 1891402863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHURCHWELL | ||||||||
| FirstName: | TREVA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN WON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2326 HORSESHOE LOOP | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722069020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015801450 | ||||||||
| FaxNumber: | 5015005897 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720153353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017766000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2022 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R85437 | AR | N | Nursing Service Providers | Registered Nurse | 163WH0200X | R85437 | AR | N | Nursing Service Providers | Registered Nurse | Home Health | 163WH1000X | R85437 | AR | N | Nursing Service Providers | Registered Nurse | Hospice | 163WX1500X | R85437 | AR | N | Nursing Service Providers | Registered Nurse | Ostomy Care | 163WW0000X | R85437 | AR | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Wound Care |
No ID Information.