Provider Demographics
NPI:1497271456
Name:KOONCE, MOLLYE JENAY (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:MOLLYE
Middle Name:JENAY
Last Name:KOONCE
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0509
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:506 LITTLE CREEK CUT OFF RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150-7798
Practice Address - Country:US
Practice Address - Phone:870-942-3000
Practice Address - Fax:870-942-3005
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR222825758Medicaid