Provider Demographics
NPI:1902660756
Name:BAHNER, NICHOLAS RODMAN (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RODMAN
Last Name:BAHNER
Suffix:
Gender:M
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:BAHNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6111 SW OSAGE ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72713-5380
Mailing Address - Country:US
Mailing Address - Phone:479-352-0657
Mailing Address - Fax:
Practice Address - Street 1:2566 E JOYCE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3923
Practice Address - Country:US
Practice Address - Phone:479-935-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR227466363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health