Provider Demographics
NPI:1528489994
Name:FITZGERALD, DEENA MICHELLE (APRN)
Entity type:Individual
Prefix:MRS
First Name:DEENA
Middle Name:MICHELLE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:DEENA
Other - Middle Name:MICHELLE
Other - Last Name:CLEVENGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:3959 N. STEELE BLVD.
Mailing Address - Street 2:SUITE 122
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-335-5777
Mailing Address - Fax:
Practice Address - Street 1:3959 N. STEELE BLVD.
Practice Address - Street 2:SUITE 122
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-335-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARS002278364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200799670AMedicaid
AR218854758Medicaid
MO420060605Medicaid