Provider Demographics
NPI:1114470549
Name:HOUSE, COURTNEY NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:HOUSE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17021 BROADLEAF
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9663
Mailing Address - Country:US
Mailing Address - Phone:870-299-2052
Mailing Address - Fax:
Practice Address - Street 1:1701 S SHACKLEFORD RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4335
Practice Address - Country:US
Practice Address - Phone:501-219-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004849363LA2200X
TXAP138503363L00000X
ARR086552163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR215626758Medicaid