Provider Demographics
NPI:1003505389
Name:SKIN DERMATOLOGY PRACTITIONER, PLLC
Entity Type:Organization
Organization Name:SKIN DERMATOLOGY PRACTITIONER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEMBERTON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:708-530-2453
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:800-824-4094
Mailing Address - Fax:479-968-1673
Practice Address - Street 1:3106 SOUTHWEST DR STE 103
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-8404
Practice Address - Country:US
Practice Address - Phone:870-641-7546
Practice Address - Fax:870-641-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-03
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty