Provider Demographics
NPI:1295780690
Name:MATLOCK, DONNA (FNP)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 S PROMENADE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-9073
Mailing Address - Country:US
Mailing Address - Phone:479-616-1485
Mailing Address - Fax:479-239-0536
Practice Address - Street 1:2012 S PROMENADE BLVD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758
Practice Address - Country:US
Practice Address - Phone:479-616-1485
Practice Address - Fax:479-239-0536
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAO1582363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO426270807Medicaid
AR148362758Medicaid
ARP00378001OtherRAILROAD MEDICARE
AR5W949Medicare PIN
ARP66632Medicare UPIN