Provider Demographics
NPI:1689035263
Name:DODD FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:DODD FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN, FNP-C
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:G
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:501-745-2713
Mailing Address - Street 1:PO BOX 1280
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031-1280
Mailing Address - Country:US
Mailing Address - Phone:501-745-2713
Mailing Address - Fax:501-745-2714
Practice Address - Street 1:933 HIGHWAY 65 N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-6607
Practice Address - Country:US
Practice Address - Phone:501-745-2713
Practice Address - Fax:501-745-2714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003662363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR192317758Medicaid
AR192317758Medicaid