Provider Demographics
NPI:1275041923
Name:HARGRAVE, MARLO RAE (NP)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:RAE
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HOSPITAL CIR STE A
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7343
Mailing Address - Country:US
Mailing Address - Phone:870-262-5545
Mailing Address - Fax:
Practice Address - Street 1:2200 MALCOLM AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3668
Practice Address - Country:US
Practice Address - Phone:870-512-2500
Practice Address - Fax:870-512-2525
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR090426163W00000X
ARA005695363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse