Provider Demographics
NPI:1407411317
Name:RETHERFORD, KATELYN (QBHP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:RETHERFORD
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:2420 LINWOOD DR STE 1
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-6122
Practice Address - Country:US
Practice Address - Phone:870-236-5880
Practice Address - Fax:870-236-5757
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR233199795Medicaid