Provider Demographics
NPI:1093433641
Name:MICKEY, JARLISA (RN, A-GPCNP-C)
Entity Type:Individual
Prefix:
First Name:JARLISA
Middle Name:
Last Name:MICKEY
Suffix:
Gender:F
Credentials:RN, A-GPCNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6039
Mailing Address - Country:US
Mailing Address - Phone:501-944-5253
Mailing Address - Fax:
Practice Address - Street 1:4 EMERALD DR
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-6039
Practice Address - Country:US
Practice Address - Phone:501-944-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR220528363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology