Provider Demographics
NPI:1255816336
Name:BRANSCUM, CAITLIN NICOLE
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:NICOLE
Last Name:BRANSCUM
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 1:707 N CARDINAL DR STE 7
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3274
Mailing Address - Country:US
Mailing Address - Phone:870-425-5644
Mailing Address - Fax:870-424-2201
Practice Address - Street 1:707 N CARDINAL DR STE 7
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3274
Practice Address - Country:US
Practice Address - Phone:870-425-5644
Practice Address - Fax:870-424-2201
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator