Provider Demographics
NPI:1104989862
Name:CANFIELD, SCOT KENNETH (PHD,APN-BC)
Entity type:Individual
Prefix:DR
First Name:SCOT
Middle Name:KENNETH
Last Name:CANFIELD
Suffix:
Gender:M
Credentials:PHD,APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8863 DEWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-4010
Mailing Address - Country:US
Mailing Address - Phone:901-752-8773
Mailing Address - Fax:
Practice Address - Street 1:703 CALVIN AVERY DR
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-6501
Practice Address - Country:US
Practice Address - Phone:870-732-1878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-17
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR01765364SP0807X
ARS01124CNS363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169462795Medicaid