Provider Demographics
NPI:1346707981
Name:MIRA, JENNIFER ROSE (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:MIRA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MERCY WAY STE 20
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-3000
Mailing Address - Country:US
Mailing Address - Phone:479-802-5555
Mailing Address - Fax:479-876-2829
Practice Address - Street 1:1 MERCY WAY STE 20
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-3000
Practice Address - Country:US
Practice Address - Phone:479-802-5555
Practice Address - Fax:479-876-2829
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily