Provider Demographics
NPI:1285654277
Name:HEAD, DEBRA J (MSE, RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:HEAD
Suffix:
Gender:F
Credentials:MSE, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 LITTLE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:ROSE BUD
Mailing Address - State:AR
Mailing Address - Zip Code:72137-9503
Mailing Address - Country:US
Mailing Address - Phone:501-556-5795
Mailing Address - Fax:
Practice Address - Street 1:3214 E RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4810
Practice Address - Country:US
Practice Address - Phone:501-380-2250
Practice Address - Fax:501-380-2251
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR523133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X145Medicare ID - Type Unspecified