Provider Demographics
NPI:1851635429
Name:RUNYON, MASHALA MONEA
Entity Type:Individual
Prefix:
First Name:MASHALA
Middle Name:MONEA
Last Name:RUNYON
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 1:615 E MCNEIL
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-3061
Mailing Address - Country:US
Mailing Address - Phone:870-949-4544
Mailing Address - Fax:
Practice Address - Street 1:1407 MALLARD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-9710
Practice Address - Country:US
Practice Address - Phone:870-562-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR6047935001Medicaid