Provider Demographics
NPI:1104459114
Name:BOHANNON, STEPHANIE L (PMHNP, APRN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:PMHNP, APRN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2566 E JOYCE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3923
Mailing Address - Country:US
Mailing Address - Phone:479-935-1000
Mailing Address - Fax:417-350-1935
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:479-935-9200
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR124030363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR259152758Medicaid
MO420098635Medicaid