Provider Demographics
NPI:1902378334
Name:RAGLAND, AMANDA JEAN (APRN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:RAGLAND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 COLUMBIA ROAD 15
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-8620
Mailing Address - Country:US
Mailing Address - Phone:479-763-8454
Mailing Address - Fax:
Practice Address - Street 1:409 WOODRUFF ST
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:AR
Practice Address - Zip Code:71826-8715
Practice Address - Country:US
Practice Address - Phone:870-894-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-25
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005787363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR231430758Medicaid