Provider Demographics
NPI:1770673246
Name:TRENTHAM, MARY A (APN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:TRENTHAM
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 SECLUDED CIR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-1718
Mailing Address - Country:US
Mailing Address - Phone:501-786-8696
Mailing Address - Fax:
Practice Address - Street 1:138 BRIGHTON TER
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-7144
Practice Address - Country:US
Practice Address - Phone:501-786-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01494363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150741758Medicaid
AR500017629OtherRAILROAD MEDICARE
5U872Medicare PIN
P12706Medicare UPIN