Provider Demographics
NPI:1396117453
Name:DARTY, PEGGY
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:DARTY
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 1:112 E CHERYL ST
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72370-2808
Mailing Address - Country:US
Mailing Address - Phone:870-563-6504
Mailing Address - Fax:870-563-7482
Practice Address - Street 1:1100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1425
Practice Address - Country:US
Practice Address - Phone:870-563-6504
Practice Address - Fax:870-563-7482
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR214376758Medicaid