Provider Demographics
NPI:1104299080
Name:BENNETT, NICOLE BAILEY (SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:BAILEY
Last Name:BENNETT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ALEXANDRA
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2740 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6141
Mailing Address - Country:US
Mailing Address - Phone:501-329-5459
Mailing Address - Fax:
Practice Address - Street 1:2740 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6141
Practice Address - Country:US
Practice Address - Phone:501-329-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR201257235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR209717721Medicaid