Provider Demographics
NPI:1497139174
Name:CONKLIN, DERRICA
Entity Type:Individual
Prefix:MRS
First Name:DERRICA
Middle Name:
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3359 W CORNELL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6775
Mailing Address - Country:US
Mailing Address - Phone:479-200-8054
Mailing Address - Fax:
Practice Address - Street 1:3359 W CORNELL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-6775
Practice Address - Country:US
Practice Address - Phone:479-200-8054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula