Provider Demographics
NPI:1114292638
Name:KATHRYN CHENAULT, MD, PA
Entity Type:Organization
Organization Name:KATHRYN CHENAULT, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHENAULT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-819-0901
Mailing Address - Street 1:2215 WILDWOOD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-5089
Mailing Address - Country:US
Mailing Address - Phone:501-819-0901
Mailing Address - Fax:501-588-3080
Practice Address - Street 1:2215 WILDWOOD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-5089
Practice Address - Country:US
Practice Address - Phone:501-819-0901
Practice Address - Fax:501-588-3080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0780261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133743001Medicaid
ARG21151Medicare UPIN
AR5J974Medicare PIN