Provider Demographics
NPI:1275112468
Name:WADDELL, ALISSA (FNP)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:
Other - Last Name:WADDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:
Practice Address - Street 1:401 EAST ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-6507
Practice Address - Country:US
Practice Address - Phone:870-216-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1021396207Q00000X
AR214732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine