Provider Demographics
NPI:1619961646
Name:SHREVE, MARILOU (DNP, APN)
Entity Type:Individual
Prefix:
First Name:MARILOU
Middle Name:
Last Name:SHREVE
Suffix:
Gender:F
Credentials:DNP, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 NW C ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4747
Mailing Address - Country:US
Mailing Address - Phone:479-422-5250
Mailing Address - Fax:
Practice Address - Street 1:900 S 52ND ST
Practice Address - Street 2:200
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8637
Practice Address - Country:US
Practice Address - Phone:479-254-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01589363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146089758Medicaid
AR146089758Medicaid