Provider Demographics
NPI:1942594437
Name:CUNNINGHAM, DERICK WADE (LMT)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:WADE
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 W WEDINGTON DR
Mailing Address - Street 2:APT 73
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-1528
Mailing Address - Country:US
Mailing Address - Phone:870-284-4029
Mailing Address - Fax:
Practice Address - Street 1:3001 W WEDINGTON DR
Practice Address - Street 2:APT 73
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-1528
Practice Address - Country:US
Practice Address - Phone:870-284-4029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6977225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist