Provider Demographics
NPI:1346472941
Name:DISTIN, DAHLIA (CNP)
Entity Type:Individual
Prefix:
First Name:DAHLIA
Middle Name:
Last Name:DISTIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 AUTUMN RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3704
Mailing Address - Country:US
Mailing Address - Phone:501-221-1941
Mailing Address - Fax:
Practice Address - Street 1:5401 JFK
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-6756
Practice Address - Country:US
Practice Address - Phone:501-758-9993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004973363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty