Provider Demographics
NPI:1407818271
Name:NOLEN, MISTY DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:MISTY
Middle Name:DAWN
Last Name:NOLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2301 SPRINGHILL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-7552
Mailing Address - Country:US
Mailing Address - Phone:501-315-0078
Mailing Address - Fax:501-943-3016
Practice Address - Street 1:2301 SPRINGHILL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72019-7568
Practice Address - Country:US
Practice Address - Phone:501-315-0078
Practice Address - Fax:501-943-3016
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4285208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR7907731OtherAETNA PROVIDER ID
AR156470001Medicaid
AR2539243OtherUNITED HEALTHCARE ID#
AR5N108OtherBCBS PROVIDER ID#
AR05040023000OtherQUALCHOICE PROVIDER ID
AR05040023000OtherQUALCHOICE PROVIDER ID