Provider Demographics
NPI:1659438448
Name:NALLS, TINA ANN (CRNA, MSNA)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:ANN
Last Name:NALLS
Suffix:
Gender:F
Credentials:CRNA, MSNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 DALLAS 262
Mailing Address - Street 2:
Mailing Address - City:SPARKMAN
Mailing Address - State:AR
Mailing Address - Zip Code:71763-8690
Mailing Address - Country:US
Mailing Address - Phone:870-687-3821
Mailing Address - Fax:
Practice Address - Street 1:638 CALIFORNIA AVE SW
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-4604
Practice Address - Country:US
Practice Address - Phone:870-836-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR202199067OtherFEDERAL ID NUMBER
AR156044001Medicaid
AR5Y331Medicare ID - Type Unspecified
AR202199067OtherFEDERAL ID NUMBER