Provider Demographics
NPI:1316557705
Name:MOONEY, WANDA FAYE (APRN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:FAYE
Last Name:MOONEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:FAYE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:870-856-2107
Practice Address - Street 1:201 S BAY DR
Practice Address - Street 2:
Practice Address - City:BAY
Practice Address - State:AR
Practice Address - Zip Code:72411-9482
Practice Address - Country:US
Practice Address - Phone:870-770-1920
Practice Address - Fax:870-994-7488
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR125714363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily