Provider Demographics
NPI:1932681905
Name:TATUM, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:TATUM
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 1:321 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:71958-9541
Mailing Address - Country:US
Mailing Address - Phone:870-285-3699
Mailing Address - Fax:870-285-3771
Practice Address - Street 1:321 E 13TH ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:AR
Practice Address - Zip Code:71958-9541
Practice Address - Country:US
Practice Address - Phone:870-285-3699
Practice Address - Fax:870-285-3771
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR222173526Medicaid