Provider Demographics
NPI:1457801797
Name:RICHARDSON, DEDRA ANN (APRN)
Entity type:Individual
Prefix:
First Name:DEDRA
Middle Name:ANN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 STATE ROUTE 142
Mailing Address - Street 2:
Mailing Address - City:MOODY
Mailing Address - State:MO
Mailing Address - Zip Code:65777-9732
Mailing Address - Country:US
Mailing Address - Phone:870-371-1482
Mailing Address - Fax:
Practice Address - Street 1:106 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-8059
Practice Address - Country:US
Practice Address - Phone:870-895-2105
Practice Address - Fax:870-895-2164
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004927363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily