Provider Demographics
NPI:1265119739
Name:OWENS, NICHOLAS REVAN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:REVAN
Last Name:OWENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEIGH
Other - Middle Name:ELIZABETH
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:
Practice Address - Street 1:710 S HOLLY ST
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3304
Practice Address - Country:US
Practice Address - Phone:479-524-8618
Practice Address - Fax:479-524-5197
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR303923795Medicaid